I can see Monkeys everywhere

Author: Suzannah Johnson, Holly Watts / Editor: Nick Tilbury / Codes: MHC1, MHP1, PhP2, RP8, SaC1, SaC3, SaP1, SLO5 / Published: 16/04/2021

You receive a pre-alert for a 16-year-old boy who has been found lying on the grass in a park with a reduced GCS. The paramedics tell you he had a half-full bottle of whiskey with him. The Prehospital observations were heart rate 130bpm, blood pressure 141/90mmHg, respiratory rate 16pm, oxygen saturation 98% on air and a temperature of 34°C.

You are told he has a history of depression and deliberate self-harm (DSH) which started a year ago, but he has never taken an overdose. He is under CAMHS who have started him on fluoxetine. Recently, he has been drinking small amounts of cider but there is no history of illicit drug use.

Prior to this presentation, he was well and had seemed to be managing OK with home schooling during lockdown.

There is a family history of late-onset epilepsy.

As you approach his bedside, he has a 30-second tonic clonic seizure which self terminates.

An initial Venous Blood Gas shows:
PH 6.930 (7.35- 7.45)
PCO2 13.6 (4.6 – 6.4 kPa)
PO2 6.51 (11.0 – 14.4 kPa)
HCO3 21 (22 – 26 mmol/l)
BE -11 (-2 – 2 mmol/l)
Hb 184 (120 – 170 g/L)
Na. 157 (133 – 146 mmol/L)
K 5 (3.5 – 5.3 mmol/L)
lactate 19 (0.5 – 2.2 mmol/L)

After the seizure, he has an ECG, which shows a sinus tachycardia with QT 300 (QTc 474) and normal QRS. His GCS is 14 and he appears to start having hallucinations, saying he can see a TV in the resuscitation room and that all the nursing staff are monkeys. He is now very agitated and over-reactive to small movements.

On examination, his chest is clear, he has normal heart sounds, and his abdomen is soft and non-tender. He is apyrexial and has no neck stiffness or rash. His pupils are normal size and equally reactive. Neurology is normal apart from not being able to follow commands for past-pointing.

On further questioning, he denies taking recreational drugs or overdose but admits that he has drunk some whiskey.