What is the best course of action for an adult or elderly patient with a history of loss of consciousness (LOC) from a fall and persistent hiccups lasting over 20 hours, possibly with pre-existing medical conditions?

Immediate Head CT and Neurological Evaluation Required

This patient requires urgent head CT imaging and neurological consultation to rule out intracranial pathology, as the combination of loss of consciousness from a fall with persistent hiccups lasting 20 hours suggests potential brainstem or posterior fossa involvement.

Critical Red Flags Present

This presentation contains two concerning features that demand immediate investigation:

• Loss of consciousness from trauma: Any LOC following head trauma requires imaging to exclude intracranial hemorrhage, contusion, or structural injury 1
• Persistent hiccups (>20 hours): Hiccups lasting beyond 48 hours are classified as persistent, but even at 20 hours with concurrent head trauma, this warrants investigation for central nervous system pathology 2, 3

Why This Combination Is Concerning

The hiccup reflex arc involves the phrenic nerve, vagus nerve, and central midbrain modulation 2. Central causes of persistent hiccups include:

• Stroke (particularly brainstem) 2
• Space-occupying lesions 2
• Traumatic brain injury 2
• Arnold-Chiari malformation (as illustrated in a case where intractable hiccups was the first prominent symptom of serious neurologic disorder) 4

The temporal relationship between head trauma with LOC and subsequent persistent hiccups raises concern for posterior fossa injury, brainstem contusion, or increased intracranial pressure affecting the hiccup reflex arc 2, 4.

Immediate Diagnostic Workup

Neuroimaging is mandatory:

• Non-contrast head CT immediately to exclude hemorrhage, mass effect, or structural injury 1
• If CT is negative but symptoms persist, consider MRI to evaluate brainstem and posterior fossa more sensitively 4

Neurological examination should specifically assess:

• Focal neurological deficits (limb weakness, ataxia, oculomotor palsies, oropharyngeal dysfunction) that would indicate vertebrobasilar involvement 1
• Signs of increased intracranial pressure
• Cranial nerve function, particularly vagus and phrenic nerve territories 2

Distinguishing Syncope vs. Traumatic LOC

While the guidelines extensively discuss syncope (transient LOC from cerebral hypoperfusion), this patient's LOC occurred from a fall, making this traumatic LOC rather than syncope 1. The key distinction:

• Syncope: LOC causes the fall 1, 5
• Traumatic LOC: The fall causes the LOC (as in this case) 1

This distinction is critical because traumatic LOC requires imaging regardless of duration, whereas uncomplicated syncope in a young healthy person may not 6.

Management of Persistent Hiccups

Only after excluding serious intracranial pathology, symptomatic treatment can be initiated:

First-line pharmacotherapy:

• Chlorpromazine: 25-50 mg PO three to four times daily; if symptoms persist for 2-3 days, parenteral therapy (25-50 mg IM) is indicated 7, 2, 8
• Baclofen: Has emerged as a safe and often effective treatment 8, 9
• Gabapentin: Alternative pharmacologic option 2

Second-line options if refractory:

• Metoclopramide (prokinetic agent) 2, 8
• Nerve blockade (phrenic nerve block) 2, 9
• In extreme cases, positive pressure ventilation with short-acting muscle relaxant has been successful 9

Common Pitfalls to Avoid

• Do not attribute persistent hiccups to benign causes when they occur in the context of head trauma with LOC 3, 4
• Do not delay imaging to trial empiric hiccup treatments first—the underlying etiology must be identified 3
• Do not assume brief LOC is benign in the setting of trauma; even "minor" head injuries can cause significant intracranial pathology 1
• Do not confuse this with vasovagal syncope, which would not explain the persistent hiccups or the traumatic mechanism 6

Disposition

• Admit for observation if imaging shows any abnormality 1
• Neurosurgical consultation if structural lesion identified 4
• Close outpatient follow-up if imaging negative, with clear return precautions for worsening headache, vomiting, altered mental status, or neurological deficits 1