For most of 2021, Ed Sheeran’s melodic “Shivers” was stuck in my head and I am hoping this post helps getting the causes of acute tremors or shivering stuck in your head ! Differential diagnosis is a medical practioner’s money-maker 💰 and that’s one thing they should always aspire to be rich in. Getting straight to it, If the clinical context of acute tremoring in a patient does not make the cause naturally evident, you could recall potential causes using the mnemonic “SHIVERS” :
S – Surgery (postanesthetic shivering) & Seizures including “Sham Seizures” (Pseudoseizures)
H – Hypoglycemia, of course !
I – Infection (Shivering can start before the actual fever, often abrupty & intensely almost like courage the cowardly dog minus the screaming ). CBC show leukocytosis or bandemia? HR doing up ? Patient feeling cold ? Check temperature more often. But remember, all fevers are not infection.
V – ok ! so we are gonna use V to remember W for Withdrawals (from Alchohol, Prescription Meds like Benzos, recreational drugs (meth, Nicotine). Patients often may hide their addictions, even from their own families, but withdrawals – just like hips – don’t lie 😉 .
E – Epinephrine related tremors (Thyrotoxicosis, Panic attack, low glucose, excessive use of meds like Albuterol ) AND worsening of Essential tremors with caffeine, illness, stress, meds
R – Reglan (metoclopramide) induced tremors / Dystonias (basically think of meds the patient got with potential for extrapyramidal effects including Neurolpetic Malignant Syndrome. Rigid? hot to touch?
S – Serotonin syndrome, especially initial mild syndrome can be just tremoring. Way too many meds can potentially cause this, including common meds like Ondansetron (Zofran), tramadol, Oxycodone, Fentanyl, Linezolid and a bunch of psychiatric meds.
That being said, I once walked in on a patient shivering in her room during a winter month and it turned out to be just an incorrectly set thermostat and lack of enough warm blankets 🤓
