Hiccups (Singultus) - Management

Definition & Classification

• Tintinalli's Emergency Medicine, p. 470-471

Causes

Benign (Acute)

• Gastric distension (food, carbonated drinks, air)
• Alcohol ingestion
• Excessive smoking
• Abrupt change in environmental/ambient temperature
• Psychogenic

Persistent / Intractable

• CNS: structural lesions (tumor, cavernous hemangioma of medulla, stroke)
• Vagal/phrenic nerve irritation: mediastinal or thoracic pathology, aortic aneurysm
• GI causes: GERD, gastric distension, peritonitis (involving diaphragmatic peritoneum)
• Metabolic: uremia (renal failure), hyperglycemia
• Post-surgical: thoracic, abdominal, craniotomy, prostate/urinary tract surgery
• Foreign body in external auditory canal pressing the tympanic membrane (auricular branch of vagus)
• Drug-induced: dexamethasone, chemotherapy, opioids, corticosteroids, benzodiazepines, antibiotics

Clinical pearl: In any hiccup patient, check for a brown dry tongue - this may indicate renal failure. Ask if hiccups resolve during sleep (resolution during sleep suggests psychogenic cause). - S. Das Manual on Clinical Surgery, p. 20

Assessment

1. Thorough history - triggering events, drug history, duration
2. Check external auditory canal for foreign body
3. Chest X-ray for chronic hiccups
4. Fluoroscopy (not ED) - unilateral diaphragmatic movement suggests focal phrenic nerve injury on affected side
5. Metabolic panel: BUN/creatinine (uremia), blood glucose

Management

Step 1 - Treat the Underlying Cause

• Paralytic ileus / gastric distension: nasogastric tube insertion and aspiration (reduces intra-abdominal pressure)
• GERD: proton pump inhibitor or H2 antagonist
• Foreign body in ear: remove it
• Drug-induced: discontinue offending agent

Step 2 - Non-Pharmacological Maneuvers

• Remove foreign body from ear
• Swallow a teaspoon of dry granulated sugar (as effective as other methods, least noxious)
• Sip or drink ice water / drink water quickly
• Breath-holding / Valsalva maneuver
• Breathing into a paper bag (increases pCO2)
• Digital rectal massage (vagal stimulation)
• Nebulized 0.9% saline 2 mL over 5 minutes
• Peppermint water (relaxes lower esophageal sphincter, facilitates belching)

Step 3 - Pharmacological Treatment

Stepwise Approach (PMC Managing Hiccups):

1. Simethicone, domperidone, or metoclopramide ± proton pump inhibitor (for GI-driven hiccups)
2. Baclofen if renal function is adequate (first-line for persistent/intractable)
3. Gabapentin (alone or add-on)
4. Chlorpromazine or haloperidol if above fail (or use earlier if renal function is impaired)
5. Consider nifedipine, valproic acid, dexamethasone, sertraline
6. Midazolam (palliative setting)

Drug Doses (from Tintinalli's EM Table 62-7):

Chlorpromazine caution: Can cause hypotension - preload with 500-1000 mL IV fluid before use. Also risk of extrapyramidal symptoms.

Renal impairment: Avoid baclofen; prefer chlorpromazine or haloperidol.

Step 4 - Interventional / Surgical (Intractable Cases)

• Phrenic nerve block (lidocaine injection)
• Phrenic nerve ablation/crushing - last resort, associated with significant morbidity, not universally successful
• Acupuncture: 4 RCTs show benefit for persistent/intractable hiccups, but studies were unblinded and uncontrolled (interpret with caution)
• Vagal nerve stimulation (implantable, used in refractory cases)
• Diaphragmatic pacing

Special Contexts

Postoperative Hiccups

• Usually from dilated stomach or paralytic ileus pressing up against the diaphragm
• First-line: NG tube decompression
• If needed: pethidine or prokinetics (siquil/metoclopramide)
• S. Das Manual on Clinical Surgery

Peritonitis / Diaphragmatic Involvement

• Repeated hiccup can be a sign of peritonitis involving the diaphragmatic peritoneum
• Treat the underlying infection

Palliative Care

• Midazolam added late in the stepwise approach
• Symptom control and quality of life are primary goals

Renal Failure

• Hiccups are a common accompaniment of advanced renal failure
• Brown dry tongue + hiccups should prompt urgent renal investigation

Recent Evidence (2025)

Documenting Patient Hand/Wrist Restraint - Nursing Notes

Why Documentation Matters

What MUST Be Included in the Note

Sample Note - Initial Restraint Application

[Date/Time] Patient is a [age]-year-old [M/F] admitted with [diagnosis, e.g., post-op day 1 abdominal surgery / ICU with delirium]. Patient noted to be repeatedly reaching toward and pulling at [IV line / NG tube / Foley catheter / wound dressing] despite repeated verbal redirection x3. Patient unable to follow commands consistently due to [altered mental status / confusion / sedation]. Risk of self-harm and dislodgement of lines assessed as high.

Alternatives attempted prior to restraint: verbal redirection x3, repositioning, re-orientation, involvement of family member at bedside - all ineffective.

Physician order obtained from Dr. [Name] at [time] for bilateral soft wrist restraints.

Bilateral soft wrist restraints applied at [time]. Restraints secured to bed frame (not side rails), allowing [2-finger breadth] slack. Bilateral radial pulses present and equal. Capillary refill < 2 seconds bilateral hands. Skin intact. No signs of neurovascular compromise.

Patient/family informed of reason for restraint use and plan for reassessment. Patient [calm / verbally protesting / attempting to remove restraints].

Will reassess every hour per protocol.

Signed: [Name, Designation]

Sample Note - Hourly Monitoring Entry

[Time] Patient in bilateral wrist restraints. Patient [calm / sleeping / intermittently agitated].

• Wrist restraints checked - secure, not excessively tight (2-finger slack maintained)
• Bilateral radial pulses: present, strong
• Capillary refill: < 2 sec bilaterally
• Skin under restraints: intact, no redness/breakdown
• Sensation: patient moving fingers bilaterally, no numbness reported
• Repositioned to prevent pressure injury
• Offered [water / toileting / ROM exercises]
• Restraints released bilaterally for 10 minutes - active ROM performed to bilateral wrists/hands
• Continued need for restraints reassessed: YES - patient still attempting to dislodge [IV/NG tube]

Signed: [Name, Designation]

Sample Note - Discontinuation of Restraint

[Date/Time] Bilateral wrist restraints removed at [time]. Patient now calm, cooperative, and following commands consistently. No longer attempting to dislodge lines. Bilateral wrists assessed - skin intact, no abrasions or redness. Pulses and capillary refill normal. Patient verbalized understanding of importance of lines/tubes. Restraint order discontinued.

Signed: [Name, Designation]

Ongoing Monitoring Requirements

• Adults (≥18 yrs): 4 hours per order
• Adolescents/children (9-17 yrs): 2 hours
• Children (<9 yrs): 1 hour

What a Poor Note Looks Like (Avoid This)

"0800 - Patient restrained. Resting comfortably."

• Does not state WHY restraints were applied
• Does not name the type or site of restraint
• Does not document neurovascular assessment
• Does not show alternatives were tried
• Does not confirm a physician order

Key Legal & Safety Points

• Restraints must never be tied to a moveable side rail - always to the bed frame
• Always leave 2-finger slack to prevent neurovascular compromise
• Document radial pulse, capillary refill, skin color, sensation, and movement at every check
• Restraints used for behavior (violent patients) have stricter timelines and require more frequent physician reassessment than those used for medical safety (line protection)
• Patient consent should be sought where possible; document attempts even if patient is unable to consent
• Family notification should always be documented