Abstract
A 58 year old man was brought to hospital in state of deep coma following severe headache for one day. His GCS was 3/15 and had flaccid all 4 limbs with equivocal planter response on both sides on arrival. NECT head showed acute subdural haemorrhage with surrounding cerebral oedema, mid-line shift and corning of brain stem. After giving mannitol and dexamethasone, four hours later, he became fully conscious and orientated; his motor power returned to normal. He was on warfarin 3mg daily for rheumatic mitral valvular heart disease with atrial fibrillation and his INR on arrival was 3.5. He had intractable hiccups once he regained consciousness. Both pharmacological and non-pharmacological measures were tried for distressing hiccups; there was no therapeutic success. His hiccups disappeared completely only after removing the haematoma by burr hole surgery.
Highlights
Hiccups is caused by involuntary contraction of diaphragm followed by the rapid closure of vocal cords
If a bout lasts more than 48 hours; it is generally considered as persistent hiccup
; hiccups was seen as one of presenting symptoms in a case with chronic subdural haematoma and the patient was free of symptom after evacuation of blood (Takemoto et al.; 2015).; it is possible that supratentorial areas involve in the either stimulation or suppression of the hiccups centers though these areas are far away from medulla
Summary
Hiccups is caused by involuntary contraction of diaphragm followed by the rapid closure of vocal cords. One of the fatal side effects of warfarin is haemorrhage in the brain: intracerebral haemorrhage; cerebellar haemorrhage and subdural haemorrhage; and the mortality rate is very high Several reports mentioned both pharmacological treatment (Lee et al.; 2010) (McGrane et al.; 2015); surgery (Tariq et al.; 2021) and non-pharmacological treatment for intractable hiccup. Twenty-four hour after rapid reversal of anti-coagulation; the patient did not suffer headache and clinical signs of raised intracranial pressure (blood pressure and heart rate) settled down He had intractable hiccups once he regained consciousness. We had to try for the best for both; prevention of clot in left atrium and cessation of further bleed in the brain He received 20 mg enoxaparin subcutaneously 10 hours after the operation; and afterward at least 40 mg enoxaparin was administered daily for thromboembolism prophylaxis. We remind the patient not to miss “the warfarin clinic” again
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