17-year-old female with cerebral palsy, epilepsy, tracheal stenosis presents as a medical alert in respiratory distress with concern for ongoing seizure activity.  She received 10 mg of diazepam at home prior to EMS arrival.   

EMS report:  

HR: 199 BP 60/43 RR: 60 SPO2: Initially 80% on room air with improvement to 98% on 15 LPM nonrebreather 

No medications given by EMS due to concern of hypotension.  

Vitals on arrival: HR 200 BP 70/50 RR 60 T 40 C SPO2 appropriate on 15 L nonrebreather  

Physical Exam 

General: agitated, nonverbal 

Skin: diaphoretic 

HEENT: normocephalic, atraumatic, pupils, equal, round and reactive, normal conjunctiva, bleeding from tongue  

Cardiovascular: tachycardiac rate, regular rhythm, cap refill 3 sec, 2+ radial pulses  

Respiratory: intercostal retractions, coarse breath sounds, inspiratory stridor 

GI: G-tube in place, soft, nondistended 

Neurologic: contracted upper and lower extremities with hypertonicity in all extremities, opisthotonic posturing, grimacing, tongue biting. 

Initial working differential diagnosis included seizure vs sepsis vs drug withdrawal vs toxin ingestion 

Mother believes patient is in pain, as seizures usually involve rhythmic shaking of extremities. She has been giving the patient oxycodone as needed for perceived arm pain. No URI symptoms.  

Home meds include clonidine, trihexyphenidyl, cannabidiol, vitamin D, and albuterol.  

PRN oxycodone and diazepam