For most of 2021, Ed Sheeran’s melodic “Shivers” was stuck in my head and I am hoping this post gets the causes of acute tremors or shivering stuck in your head! Differential diagnosis is a medical practitioner’s money-maker 💰 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 abruptly & intensely almost like courage the cowardly dog minus the screaming ). Does CBC show leukocytosis or just bandemia? HR doing up? Patient feeling cold? Check temperature more often. But remember, all fevers are not infections.
V – We are gonna use V to remember W for Withdrawals (from Alchohol, Prescription Meds like Benzodiazepines, 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 Neuroleptic Malignant Syndrome (NMS). 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 & 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 🤓
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