YAJEM-56378; No of Pages 3

American Journal of Emergency Medicine xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

A case of singultus: Avoiding a hiccup in care

Jeffrey Gardecki ⁎, James Espinosa, Alan Lucerna, Jarrid Bernhardt
Department of Emergency Medicine, Rowan University SOM Kennedy University Hospital, Stratford, NJ, USA

a r t i c l e i n f o a b s t r a c t

Article history: Hiccups (singultus) is often a benign, common and self- limited condition. A case of profound electrolyte distur-
Received 16 December 2016 bances presenting with chief complaint of hiccups is presented in which chlorpromazine was not administered
Accepted 21 December 2016 and could have been problematic had it been given. For those who present to the ED with chief complaint of hic-
Available online xxxx
cups, it is critical to consider a life threatening etiology as the cause of their symptom. This case presents a poten-
tial pitfall in the management of singultus.
Keywords:
Singultus
© 2016 Published by Elsevier Inc.
Hiccups
Singultus with hyponatremia
Hiccups with hyponatremia
Emergency department evaluation of hiccups
Emergency department evaluation of singultus

1. Case presentation
A 47-year-old male presented to the emergency department (ED)
with a report of hiccups. The patient reported the hiccups had been con-
stant for the preceding nine days and had been interfering with his
sleep. He stated that the onset of this symptom coincided with eating
a hardboiled egg. He reported drinking large quantities of an electrolyte
sports drink and water in an attempt to ameliorate his hiccups–with no
success.
He related shortness of breath and a nonproductive cough over this
period. The patient's past medical history was significant for an unpro-
voked pulmonary embolism diagnosed six months prior to his ED pre-
sentation. He had been largely noncompliant with an outpatient
regimen of rivaroxaban (Xarelto), which was his only outpatient medi-
cation. The patient denied any other significant medical conditions and
denied any history of prior surgery. His social history was significant for
daily alcohol consumption of two shots of whiskey daily. He was a cur-
rent cigarette smoker and had smoked a pack of cigarettes daily for
30 years. He denied any illicit drug use. He denied any food or drug
allergies.
His initial presenting vital signs were within normal limits, with
a heart rate of 97 beats per minute (bpm), a blood pressure of
116/63 mm Hg, an oral temperature of 97.8 °F and a respiratory rate
of 16 breaths per minute. He was in no apparent distress except for
the frequent episodes of hiccups while being examined.
⁎ Corresponding author at: Department of Emergency Medicine, Rowan University
SOM Kennedy University Hospital, 18 East Laurel Road, Stratford, NJ 08084, USA.
E-mail address: gardeckij@gmail.com (J. Gardecki).
Pupils were noted to be equal, reactive, and non-icteric. Neck exam
showed no jugular venous distention and trachea was noted to be mid-
line. Cardiac auscultation revealed a regular rate and rhythm. Pulmo-
nary exam was noted to be free of wheezes, rales, or rhonchi. His
abdomen was soft, non-tender, non-distended and free of signs of vari-
cosity. No focal sensory deficits or focal motor weakness was noted on
examination of the upper or lower extremities.
The emergency physician ordered a complete blood count, basic
metabolic panel, electrocardiograph, chest X-ray, pro-thrombin, partial
thromboplastin time.
Significant results included a sodium of 121 mmol/l, potassium of
1.5 mmol/l, chloride of 63 mmol/l, bicarbonate of 63 mmol/l, creatinine
of 0.70 mg/dl, and BUN of 5 mg/dl. An electrocardiograph was per-
formed [Image 1], and showed a normal sinus rhythm with a rate of
98 bpm. He also had a markedly prolonged QTc at 612 ms. The chest
X-ray was noted to display increased vascular markings and a linear
scar in the left upper lung field [Image 2].
At this point the patient's hiccups were referred to by the treatment
team both by the patient's complaint of hiccups as well as by the med-
ical term—singultus.
The initial consideration was given to the administration of chlor-
promazine 25 mg intravenously for the empiric treatment of the
patient's singultus. The patient's EKG and lab results were available
prior to the administration of chlorpromazine. The chlorpromazine or-
dered was cancelled. The patient was subsequently administered a 1 l
bolus of normal saline, potassium chloride 20 milliequivalent (meq) in-
travenously as well as 40 meq of potassium orally. 2 mg of magnesium
sulfate were given intravenously. He was admitted to the intensive care
unit for close monitoring of critical electrolyte derangement including

http://dx.doi.org/10.1016/j.ajem.2016.12.056
0735-6757/© 2016 Published by Elsevier Inc.

Please cite this article as: Gardecki J, et al, A case of singultus: Avoiding a hiccup in care, American Journal of Emergency Medicine (2016), http://
dx.doi.org/10.1016/j.ajem.2016.12.056
2 J. Gardecki et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Image 1. ECG on presentation.
hyponatremia, hypokalemia, and metabolic alkalosis. The patient's
symptoms resolved on the second day of hospitalization.
2. Discussion
Singultus is the proper medical term for the commonly used ono-
matopoetic word hiccup. The term singultus is thought to have been de-
rived from the Latin term singult, which has been translated to mean
the act of attempting to catch ones breath while sobbing [1]. The phys-
ical act of singultus is thought to be a primitive reflex consisting of an in-
termittent, spasmodic contraction of the inspiratory muscles of
respiration involving the diaphragm and external intercostal muscles
followed by immediate closure of the glottis [2,3]. It has been postulated
that hiccups may serve the function of dislodging food obstructing the
esophagus, as they are commonly associated with eating [4].
Image 2. Chest X-ray on presentation.
Please cite this article as: Gardecki J, et al, A case of singultus: Avoiding a hiccup in care, American Journal of Emergency Medicine (2016), http://
dx.doi.org/10.1016/j.ajem.2016.12.056
The list of identified etiologies for singultus is expansive and num-
bers well over 100 possible causes [2]. There are many proposed physi-
cal or pharmacological treatments for singultus [5].
It is useful to distinguish between hiccups based on duration. Nearly
everyone has experienced brief, self-limited hiccups which resolve
spontaneously. Multiple hiccups lasting b 48 h in duration have been re-
ferred to as a hiccup bout. Episodes lasting longer than 48 h are referred
to as persistent hiccups [1]. Hiccups lasting longer than two months are
called intractable hiccups [3]. Benign self-limited hiccups typically do
not require any further evaluation or treatment and are commonly a re-
sult of gastric distention from overconsumption of food or alcohol [2].
The patient with persistent or intractable hiccups requires a thorough
evaluation for serious or potentially life-threatening etiologies.
In order to understand the potential etiologies of hiccups it is useful
to describe the proposed mechanism for which hiccups take place.
The hiccup arch is a neural reflex consisting of an afferent limb, cen-
tral connection, and an efferent limb. The afferent limb is believed to re-
ceive input from the phrenic nerve, vagus nerve, and T6-T12
sympathetic afferents [1,2,4]. The central connection has been postulat-
ed to involve a supra-spinal center functioning independent of the
brain-stem nuclei involved in the process of respiration [2]. The primary
component of the efferent limb is the phrenic nerve with accessory out-
put to the glottis and external intercostal muscles [2,4].
The etiologies for singultus can be viewed in the context of which
component of the reflex arch with which they interfere. Those affecting
the afferent or efferent branches are believed to be the most common,
specifically the irritation of the peripheral branches of the phrenic and
vagus nerve by over ingestion of food or alcohol [1]. Drug, toxin, or met-
abolically mediated etiologies for singultus act through either suppres-
sion of the normal suppressive function of the CNS inhibitory
pathways or through there direct stimulation of the peripheral nerves
[1]. Additional central causes for singultus include: hydrocephalus,
ventriculo-peritoneal shunts, multiple sclerosis, ischemic or hemor-
rhagic strokes, traumatic conditions such as diffuse axonal injury, cere-
bral contusions, epidural or subdural hematomas, encephalitis,
meningitis, brain abscesses, and neurosyphilis [1]. Stimulation of the af-
ferent component of the reflex arch, specifically the vagus nerve, can
occur at any location during its course. Associated etiologies of singultus
 J. Gardecki et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
arising from the vagus nerve include: pharyngeal activation from phar-
yngitis, laryngitis, retropharyngeal abscess, peritonsillar abscesses, au-
ricular activation through irritation of the tympanic membrane, or
stimulation of the thoracic component from esophagitis, bronchitis,
mediastinitis, pneumonia, myocardial infarction, pericarditis, thoracic
or aortic aneurysm [1,2,5]. Stimulation of the either the afferent or effer-
ent limb by stimulation of the phrenic nerve can cause singultus
through: direct irritation of the diaphragm by gastric distention due to
overeating or alcohol consumption, aberrant pacemaker lead position,
intraoperative diaphragm irritation during abdominal procedures,
small bowel obstruction, pericarditis, perihepatitis, subphrenic abscess,
goiter, tumor, or cyst of the neck [1,2,5]. Certain medications have also
been implicated in the development of hiccups. These include steroids,
methyldopa, barbiturates, and certain anesthetic agents [5].
Electrolyte derangements are a well recognized etiology for
singultus. Hyponatremia in particular has been reported as a cause for
persistent and intractable hiccups [1].
The patient in our case presented with a sodium of 121 mmol/l, as
well as a potassium of 1.5 mmol/l.
The general approach to hiccup management should begin with ap-
propriate identification and subsequent removal of any known etiolo-
gies of singultus [1,3].
If no specific reversible etiology is identified, symptom-directed
therapies are often employed. Many techniques have been used in the
treatment of hiccups ranging from physical maneuvers to medication
administration. Some non-pharmacological therapies include
swallowing granulated sugar or nasogastric tube stimulation of the hy-
popharynx, which is thought to inhibit vagal afferent portions of the hic-
cup reflex arch [1,4,5].
In the case of persistent or intractable hiccups, the use of pharmaco-
logical therapies are often employed. Chlorpromazine is the only phar-
macological US Food and Drug Administration approved agent for the
treatment of hiccups. It is the most commonly used agent [3]. Chlor-
promazine is a phenothiazine antipsychotic that can be administered ei-
ther orally, intravenously or intramuscularly. Common side effects of
chlorpromazine administration include hypotension, sedation, and uri-
nary retention [4].
When faced with the complaint of hiccups, a detailed history and
physical should be performed with directed investigation towards po-
tential etiologies. Kolodzik et al. recommend a chest radiograph as
“the most useful routine laboratory screening examination for the pa-
tient with hiccups” [1]. Additional testing may include complete cell
Please cite this article as: Gardecki J, et al, A case of singultus: Avoiding a hiccup in care, American Journal of Emergency Medicine (2016), http://
dx.doi.org/10.1016/j.ajem.2016.12.056
3
count, basic metabolic panel, alcohol level, and commonly an electrocar-
diograph [1].
In this case, the results of the ECG and lab testing served an impor-
tant function in preventing administration of chlorpromazine.
The concern for the administration of chlorpromazine in the setting
of QTc prolongation is that it can lead to polymorphic ventricular tachy-
cardia, specifically torsades de pointes. This malignant arrhythmia can
further degenerate to ventricular fibrillation and subsequently sudden
cardiac death [6]. The torsadogenic potential of chlorpromazine is
established with a University of Arizona's Center for Research on Ther-
apeutics score of 1 which equates to a generally accepted elevated risk
of torsades [6]. Of note, the hypokalemia seen in this case was an addi-
tional risk factor known to be associated with QTc prolongation [6].
This case highlights a potential pitfall in the routine administration
of the most commonly used medication to treat hiccups and further un-
derscores the necessity of considering underlying etiologies before
moving to treatment.
3. Conclusion
Singultus is usually not life threatening and is most often self-limited
in nature. The case presented depicts a clinical encounter in which per-
sistent hiccups are a presenting complaint for a potentially life threaten-
ing metabolic derangement. It is important to always consider life
threatening causes for the complaint of hiccups when they are persis-
tent or intractable in nature. This case highlights a potential pitfall in
the routine administration of the most commonly used medication to
treat hiccups and further underscores the necessity of considering un-
derlying etiologies before moving to treatment.
References
[1] Kolodzik PW, Eilers MA. Hiccups (singultus): review and approach to management.
Ann Emerg Med May 1991;20:565–73.
[2] Loft LM, Ward RF. Hiccups: a case presentation and etiologic review. Arch Otolaryngol
Head Neck Surg Oct 1992;18:1115–9.
[3] Rizzo C, Vitale C, Montangnini M. Management of intractable hiccups: an illustrative
case and review. Am J Hosp Palliat Med 2014;31(2):220–4.
[4] Wagner MS, Stapczynski JS. Persistent hiccups. Ann Emerg Med Jan 1982;11:24–6.
[5] Howard RS. Persistent hiccups. BMJ 1992;305:1237.
[6] Wenzel-Seifert K, Wittman M. QTc prolongation by psychotropic drugs and the risk of
torsades de pointes. Dtsch Arztebl Int 2011;108(41):687–93.