Neuropsychiatric and Autonomic Manifestations of Ketamine Toxicity in a 24-Year-Old Male

Ketamine, a dissociative anesthetic with therapeutic and recreational applications, poses significant toxicological risks, particularly when misused. This case report describes a 24-year-old male who presented to the emergency department with altered mental status, agitation, visual hallucinations, hyperthermia (103°F), and respiratory distress, including stridor and intermittent laryngospasm, following suspected recreational drug use. Clinical findings such as dilated pupils, horizontal nystagmus, rhabdomyolysis (elevated creatine kinase), leukocytosis, hypoglycemia, and mild phencyclidine (PCP) positivity suggested ketamine toxicity as the primary diagnosis. The patient required rapid-sequence intubation for airway protection, along with intravenous benzodiazepines for agitation and sympathetic overactivity, and aggressive intravenous (IV) fluid resuscitation for rhabdomyolysis. Hyperthermia was addressed with external and internal cooling methods. Sodium bicarbonate therapy was initiated to alkalinize urine due to creatine kinase (CK) elevation, and preparations for managing potential hyperkalemia were made. Imaging revealed bladder and ureteric wall thickening, raising suspicion of ketamine-induced cystopathy and prompting urologic evaluation. Given the severity of symptoms, the patient was admitted to the intensive care unit (ICU) for further monitoring and management. Activated charcoal was withheld due to timing and airway protection. This case emphasizes the importance of early recognition and comprehensive supportive care in ketamine toxicity, particularly when complicated by airway compromise, rhabdomyolysis, and hyperthermia, and underscores the role of psychiatric evaluation in suspected substance misuse.