Community-acquired lobar pneumonia caused by Pseudomonas aeruginosa infection in Japan: a case report with histological and immunohistochemical examination.

Pseudomonas aeruginosa is a common pathogen in nosocomial and/or healthcare-associated pneumonia, but is rare in community-acquired pneumonia. A 50-year-old previously healthy woman was taken to the emergency department because of rapidly progressing dyspnea. Chest radiograph showed consolidation of the entire right upper lobe, a finding suggestive of lobar pneumonia. The patient died of respiratory failure with bronchial bleeding, on the same day of admission. Autopsy revealed that the alveoli throughout the upper right lobe were filled with dense inflammatory cells mainly consisting of macrophages and neutrophils. Immunoreactive bacilli by using an anti-P. aeruginosa antibody were localized within macrophages accumulated in the alveoli as well in the vessel walls. Lobar pneumonia composed of dense neutrophils and bacteria-laden macrophages with total lung congestion and edema may be characteristic for community-acquired P. aeruginosa pneumonia in a healthy adult.

A case of degloving injury of the colon.

The left side of a truck driven by a 71-year-old man was hit by another car at an intersection, and his abdomen was compressed by the steering wheel. On arrival, he complained of severe lower abdominal pain; and physical examination demonstrated involuntary rigidity and rebound tenderness. Enhanced truncal computed tomography exhibited that the descending colon was shifted ventral and medial because of a low-density mass with contrast extravasation. An emergency laparotomy disclosed injuries of the descending colon, which could be mobile because of degloving of the colon, left mesenterium, spleen, and tail of pancreas. During resection of these injured organs, difficulty in controlling the bleeding from the degloving injury site resulted in the requirement of a "second look" operation. The postoperative course was eventful; however, the patient's physiologic condition stabilized, and he was discharged on foot on the 108th hospital day.

A case of thoracic degloving injury with flail chest.

A 75-year-old male patient suffered a chest degloving injury when he fell on his back and was run over by a small farm tractor he was pulling. At the time of patient admission, the paradoxical motion of the right chest wall was remarkable; and he had an open fracture of the right humerus, a dislocation of the right ankle, and a laceration of the right forearm. Chest computed tomography revealed fractures of the fifth to seventh ribs and detachment of both the right pectoralis major muscle and serratus anterior muscle from the chest wall, with a disconnected right thoracic cavity. Because the right flail chest was severe and there was a large amount of air leakage that continued under positive-pressure ventilation for pneumatic stabilization, we performed surgical fixation of the ribs and repaired the lung injury on the fifth hospital day. The patient's postoperative course was uneventful.

Usefulness of computed tomography in the diagnosis of an overdose.

Computed tomography (CT) is superior for the detection of substances with low radiolucency in comparison with abdominal roentgenograms. In the present study, medical chart review was retrospectively performed for patients who were admitted and underwent plain CT including the stomach on arrival to investigate whether CT is useful for diagnosing overdose (OD). The subjects were divided into patients with OD who did not undergo gastric lavage (OD group) and those without OD (Control group). The presence of a radiopaque area (Hounsfield number over 100 on a range of interest of 3 mm2) in the stomach on CT was defined as a positive finding. The average Glasgow Coma Scale in the OD group (n=11) was significantly lower than that in the Control group (n=137). Positive findings on CT were found more frequently in the OD group than in the Control group (100 vs. 19.7%, p＜0.0001). Based on the finding of a high-density deposition in the bottom of the stomach, the CT predicted OD with 98.5% specificity. Accordingly, CT findings of a high-density deposition in the stomach of a patient with a diminished consciousness may suggest the presence of a recent overdose.

[Investigation of the Hounsfield number of drugs in stomach using computed tomography in vitro].

BACKGROUND: A high density area (HDA) that may represent ingested drugs was detected in the stomach of a patient with a drug overdose (OD) by computed tomography (CT). However, there is no prior evidence that drugs can be visualized as an HDA by abdominal CT. We investigated whether drugs can be imaged as an HDA by CT. METHODS: Ten tablets, 5 tablets, 1 tablet and 0.1 tablet of either Solanax (0.4 mg) or Depas (0.5 mg) or Tryptanol (10 mg) or Paxil (10 mg) or Wintermin (25 mg) or Phenobal (30 mg) or Hiberna (25 mg) were each added to 10 ml of artificial gastric juice. We then measured the Hounsfield numbers immediately after mixing, 1 hour later and 7 hours later using CT images. RESULTS: All of the drugs precipitated in the artificial gastric juice and these precipitations were imaged as HDAs over 100 Hounsfield units. Moreover, the drugs maintained high Hounsfield numbers after 7 hours although there was a trend to decrease sequentially. CONCLUSION: We demonstrated that the precipitated drugs in the artificial gastric juice could be imaged as HDAs by CT.

Photoacoustic monitoring of granulation tissue grown in a grafted artificial dermis on rat skin.

In this study, we investigated the validity of photoacoustic (PA) measurement for monitoring granulation tissue and hence adhesion of grafted artificial dermis (AD). A 2.5 cm x 2.5 cm, 3-mm-thick AD composed of an atelocollagen sponge sheet and a silicone film was grafted on a full-thickness open wound in rat dorsal skin. The grafted AD was irradiated with low-energy, 532-nm nanosecond laser pulses to photoacoustically excite blood in neovascularities, and the PA signals induced were measured using a piezoelectric transducer as a function of postgrafting time. The PA signals were compared with results of laser Doppler imaging and histological analysis. We found a significant correlation between the depths of the first or shallowest PA signal peaks and the depths of granulation tissues estimated from histology with hematoxylin & eosin staining (R=0.951, p<0.05). There was also a significant correlation between the amplitudes of the first PA signal peaks and densities of CD31-positive cells evaluated from histology with immunohistochemical staining (R=0.859, p<0.05). With laser Doppler imaging, no clear perfusion signals were observed, which is attributable to a high light scattering loss in ADs. These findings suggest the validity of PA measurement for monitoring the adhesion of grafted ADs.

Relationship between abnormal pupillary reactivity and the outcome of a psychotropic drug overdose.

OBJECTIVE: The association between abnormal pupil reactivity (abnormal) and the outcome among patients with psychotropic drug overdose (OD) was retrospectively investigated. METHODS: The study included patients that had experienced an OD between January and December 2007. The subjects were divided into 2 groups, namely, abnormal and normal groups. RESULTS: There were 12 subjects in the abnormal and 74 subjects in the normal group. Glasgow Coma Scale in the abnormal was significantly smaller that that in the normal group. An average quantity of ingested tranquilizer per subject in the abnormal was significantly larger that those in the normal group. However, the duration of admission and survival rates between the two groups were not significantly different. CONCLUSION: The patients that experienced an OD, who demonstrated abnormal pupil reactivity, tended to have ingested larger amounts of drugs while also demonstrating severe unconsciousness. However, the patients with abnormal pupil reactivity had a favorable outcome.

Therapeutic mild hypothermia: effects on coagulopathy and survival in a rat hemorrhagic shock model.

OBJECTIVE: : To determine the effects of therapeutic hypothermia on coagulation parameters during hemorrhagic shock (HS) and fluid resuscitation and on survival, in a rat HS model. METHODS: : Under light anesthesia and spontaneous breathing, 24 rats underwent HS (phase I) for 90 minutes, during which 2.5 mL/100 g blood was withdrawn over 15 minutes; fluid resuscitation (phase II) for 60 minutes, during which no blood was reinfused but 5.0 mL/100 g lactated Ringer's solution was infused over 30 minutes; and an observation (phase III) without anesthesia until 72 hour. After the volume-controlled hemorrhage, rats were randomized into a hypothermia group (n = 12, 33 degrees C) or a normothermia group (n = 12, 38 degrees C). The rectal temperature in each group was maintained during phases I and II. Whole blood coagulopathy was assessed by Sonoclot analysis (SA) at baseline and the end of phases I and II. Fibrinolysis parameters of thrombin-antithrombin III complex and plasma-alpha-2-plasmin inhibitor complex were also monitored. RESULTS: : At 72 hour, 10 of 12 hypothermia group rats, and 5 of 12 normothermia group rats remained alive (p < 0.05). Fluid resuscitation significantly decreased hematocrit (20% +/- 5%) compared with baseline (33% +/- 5%; p < 0.05) in all rats. SA showed no significant differences between groups at the end of phase I. However, at the end of phase of II, SA revealed a decreased "clot rate" in hypothermia compared with normothermia (22 clot signal/min +/- 11 clot signal/min vs. 34 clot signal/min +/- 14 clot signal/min; p < 0.05) and a prolonged "time to peak" in hypothermia (15 minutes +/- 5 minutes versus 6 minutes +/- 2 minutes; p < 0.05). No differences in thrombin-antithrombin III complex and plasma-alpha-2-plasmin inhibitor complex values were seen between groups throughout the experiment. CONCLUSIONS: : Therapeutic mild hypothermia of 33 degrees C did not cause coagulopathy during HS, but did impair SA coagulation parameters during fluid resuscitation, probably because of dilution. Hypothermia also prolonged survival after HS. Impairments to coagulation parameters did not worsen outcomes in the rat HS model.

Improved survival time with combined early blood transfusion and fluid administration in uncontrolled hemorrhagic shock in rats.

OBJECTIVE: To test whether early blood administration combined with crystalloid solution infusion may prolong survival in a clinically relevant model of ongoing uncontrolled life-threatening hemorrhage. METHODS: Light anesthesia was induced with halothane in 24 rats, and spontaneous breathing was maintained. Uncontrolled hemorrhagic shock was induced by withdrawal of blood at 2.5 mL/100 g over a 15-minute period, followed by 75% tail amputation. At 10 minutes after tail cutting, rats were randomized into four groups (n = 6 each): group 1, receiving 3 mL of shed blood for 5 minutes followed by 9 mL of lactated Ringer's (LR) solution for 15 minutes; group 2, receiving 9 mL of LR solution for 15 minutes followed by 3 mL of shed blood for 5 minutes; group 3, receiving 9 mL of LR solution only for 15 minutes; group 4, receiving neither of shed blood nor LR solution. Rats were then observed until death or a maximum of 180 minutes. RESULT: Mean survival time was 138 +/- 30 minutes, 108 +/- 22 minutes, 79 +/- 13 minutes, and 55 +/- 18 minutes for groups 1, 2, 3, and 4, respectively (p < 0.05 among the four groups). Additional blood loss from the tail stump did not differ significantly between the three treatment groups. CONCLUSIONS: In a model of uncontrolled hemorrhagic shock in rats, a resuscitation regimen using crystalloids agent alone is not ideal, and even a brief delay in blood administration worsens survival. Early blood administration combined with crystalloid solution infusion seems ideal.

Analysis of prehospital care for cardiac arrest in an urban setting in Japan.

BACKGROUND: In Japan, the management of prehospital care for cardiopulmonary arrest (CPA) has recently changed. STUDY OBJECTIVES: The characteristics of prehospital care for CPA were analyzed to identify predictors of prehospital return of spontaneous circulation (PROSC) and good recovery. METHODS: The characteristics of prehospital management of 713 out-of-hospital CPA patients in the First Western District of Saitama Prefecture, Japan, were retrospectively analyzed. RESULTS: Overall, PROSC rate was 9.5% (n = 68), and 2.2% of patients (n = 16) made a good recovery. Significant positive predictors of PROSC were: duration from the first call to hospital arrival, witnessed collapse, ventricular fibrillation at scene, and epinephrine administration. Establishment of supraglottic airway was a significant negative predictor of PROSC. Significant positive predictors of good recovery were younger age, ventricular fibrillation at scene, and PROSC. Changes to the life support protocol based on 2005 guidelines did not affect the outcome. CONCLUSIONS: Epinephrine was effective in increasing PROSC; however, it did not improve recovery of such patients. The findings also suggest that out-of-hospital care providers should not try to establish a supraglottic airway.

Clinical significance of plasma ammonia in patients with traumatic hemorrhage.

BACKGROUND: Hemorrhagic shock has been reported to elevate the concentration of ammonia in the blood of animals. However, only one clinical study, of a few surgical patients, found a similar effect. This investigation sought to determine whether ammonia is elevated in the plasma of trauma patients with hemorrhage and whether it could be used to predict serious hemorrhage. METHODS: Subjects were consecutive trauma patients admitted to our Level I trauma center between November 2006 and April 2008 who met the inclusion criteria to determine plasma ammonia. Their blood was sampled at admission. Patients who required blood transfusion > or = 2 U or intervention for bleeding within 24 hours were classified into a bleeding group. Patients who did not require a transfusion or interventions were classified as controls. In addition to routine hemodynamic measurements, we recorded the hourly infused volume of Ringer's lactate solution (infusion volume) during emergency room treatment and total transfused blood volume within the first 24 hours. RESULTS: The subjects were 282 trauma patients. Their mean age was 44.0 +/- 20.4 years old, and their mean injury severity score was 15.8 +/- 13.1. Ammonia was significantly correlated with systolic blood pressure, shock index at admission, infusion volume, base deficit, and injury severity score. Forty-one patients required blood transfusion and 31 needed intervention for arterial bleeding. Because some patients required both therapies, the bleeding group consisted of 46 patients. The control group consisted of 236 patients who needed neither blood transfusion nor intervention. The plasma ammonia concentration in the bleeding group (113 +/- 52.2 microg/dL) was significantly higher than in the control group (55.4 +/- 20.8 microg/dL). In the bleeding group, the ammonia concentration of patients who died from bleeding (170 +/- 68.7 microg/dL) was significantly higher than in survivors (102 +/- 40.7 microg/dL). The best ammonia concentration cutoff value that maximized sensitivity and specificity to select for the bleeding group was > or = 77 microg/dL (sensitivity, 82%; specificity, 89%). CONCLUSIONS: Elevated plasma ammonia concentration at admission can be a clinically significant indicator for traumatic hemorrhage that requires treatment.

Relationship between laboratory findings and the outcome of cardiopulmonary arrest.

PURPOSE: The aim of this study was to investigate whether laboratory findings on arrival may be useful in predicting the outcome of out-of-hospital cardiopulmonary arrest (CPA). METHODS: Between January 2005 and September 2007, a medical chart review was retrospectively performed for CPA. The individual medical records were reviewed for the following data: background of CPA, arterial blood gas, cell blood count, serum biochemical, and cerebral performance category (CPC) 1 month after the CPA. The subjects were divided into patients with a CPC ranging from 3 to 5 (CPC 3-5 group) and from 1 to 2 (CPC 1-2 group). FINDINGS: The total protein, platelets, pH, and Po(2) in the CPC 1-2 group tended be higher than those in the CPC 3-5 group. The Pco(2), potassium, phosphorus, and ammonia in the CPC 1-2 group tended be lower than those in the CPC 3-5 group. However, there were no factors independently associated with the outcome by multivariate analysis. CONCLUSION: Some of the biochemical-hematologic parameters demonstrate significant changes concerning the outcome. However, initial blood work cannot be used to make clinical decisions because there are no factors independently associated with the outcome.

Relationship between maximum intracranial pressure and traumatic lesions detected by T2*-weighted imaging in diffuse axonal injury.

BACKGROUND: We prospectively investigated whether the number of traumatic lesions detected by magnetic resonance imaging correlated with the level of intracranial pressure (ICP) and outcome among patients with diffuse axonal injury (DAI). MATERIALS: We prospectively studied 19 patients with closed head injuries who were admitted to the Critical Care and Trauma Services at our medical center and who fulfilled the following criteria: did not recover to a Glasgow Coma Scale score greater than 8 after impact, without fixed dilated pupils, and with initial computed tomography findings compatible with DAI. All subjects (n = 19) underwent ICP monitoring for at least 4 days, and T2*-gradient echo imaging was performed within 4 weeks of the impact. RESULTS: A significantly positive correlation was found between the number of lesions detected by magnetic resonance imaging and maximum ICP. The average Glasgow Coma Scale in the good outcome group (Glasgow Outcome Scale IV and V, n = 8) was significantly greater than that in the poor outcome group (Glasgow Outcome Scale I-III, n = 11). The average maximum ICP and the number of lesions in the good outcome group were significantly less than those in the poor outcome group. CONCLUSION: The number of lesions detected by T2*-gradient echo imaging correlates with the degree of intracranial hypertension and outcome in DAI.

Characteristics of pediatric trauma in an urban city in Japan.

OBJECTIVES: To clarify the characteristics of recent pediatric injuries in an urban city in Japan. METHODS: Any patient who was under 13 years old and admitted for treatment of trauma between January 2000 and December 2007 was retrospectively investigated. The subjects were divided into 2 groups, the head injury (HI) and the control groups. The HI group had an abbreviated injury score (AIS) of the head greater than 1, and the control group had an AIS of the head equal to 0 or 1. RESULTS: The number of patients in the HI group was 95; and in the control group, 74. There were no penetrating injuries. The proportion of patients who were run over in the HI group was smaller than that in the control group. The injury severity score in the HI group was greater than that in the control group. The abdominal AIS in the HI group was smaller than that in the control group. The number of extracranial injuries (sum of all AIS except for the head) in the HI group was smaller than that in the control group. The survival rate in the HI group was smaller than that in the control group. All causes of death in the HI group were cerebral complications. CONCLUSIONS: The severity and outcome of pediatric blunt traumas were dependent on HI. Because the extracranial injuries with an HI were not severe, the successful treatment of the cerebral complications could lead to favorable outcome.

Predicting the development of anemia by measuring the diameter of the inferior vena cava of patients with spinal cord injury.

PURPOSE AND METHODS: We retrospectively investigated whether measurement of the diameter of the inferior vena cava (IVC) is useful in predicting the development of anemia in 12 patients with spinal cord injury. Measurement of the IVC was performed in conjunction with computed tomography scan upon arrival. The subjects were divided into two groups: those with a minimum (Min) hemoglobin (Hb) of less than 10 g/dL, and those with a Min Hb greater than 10 g/dL during hospitalization. RESULTS: The average diameter of IVC in the Hb<10 g/dL group was smaller that that in the Hb>10g/dL group. Blood pressure was not significantly different between the two groups. The difference between the Min and initial Hb value and incidence of blood transfusion in the Hb<10g/dL group was significantly greater than that in the Hb>10g/dL group. CONCLUSION: To predict the development of anemia, measurement of the IVC of patients with spinal cord injury may therefore be useful.

Indications for transcatheter arterial embolization in persistent hemothorax caused by blunt trauma.

BACKGROUND: To confirm the usefulness of contrast-enhanced computed tomography (CECT) and the efficacy of transcatheter arterial embolization (TAE) in patients, who undergo tube thoracostomy for hemothorax secondary to blunt chest trauma. MATERIALS: CECT was performed at admission in patients, who suffered blunt chest trauma but did not require an emergent thoracotomy. Pulmonary injuries with intrapulmonary hematomas or traumatic pneumatoceles or both on computed tomography images were diagnosed as pulmonary lacerations (PL). The size of the pulmonary injuries with the PL was measured as percent volume (volume of the PL/volume of the lung). Rib fracture displacement was measured on computed tomography images and expressed as parallel and transverse displacement of the fractured ribs (PD and TD, respectively). Patients with an injury to a thoracic great vessel (e.g., aortic injury) were excluded. RESULTS: CECT of the chest was performed on 154 of 976 consecutive patients with blunt torso trauma. Thirty-four patients have PL without a great vessel injury. Tube thoracostomy was performed at 38 sites in 29 patients. After the initial bloody drainage, the mean drainage during the first hour was 81.2 mL/h +/- 137 mL/h. The mean percent volume of the PL was 29.0% +/- 15.4%. The mean PD was 12.2 mm +/- 10.4 mm. The PD and the TD correlated with the hourly drainage (p = 0.001, p < 0.001, respectively). No correlation was found between the percent volume of PL and hourly drainage (p = 0.11). Of the 38 thoracostomy sites, 6 had a blood loss of > or =200 mL/h. Contrast extravasation on CECT was observed in five of these six sites, and angiography was performed. All five sites had contrast extravasation from an intercostal artery, and TAE was successfully performed. CONCLUSION: Intercostal arterial bleeding should be suspected in patients with persistent hemothorax > or =200 mL/h and large displacement of a fractured rib. In such cases, CECT should be performed and TAE is indicated if contrast extravasation is observed.

Predicting the development of anemia by measuring the diameter of the inferior vena cava for children with blunt injuries.

OBJECTIVE: We retrospectively investigated whether or not the measurement of the diameter of the inferior vena cava (IVC) was useful for predicting the development of anemia. METHODS: We performed a medical chart review to seek patients who were younger than 12 years, were experiencing blunt injury, and received an abdominal computed tomographic scan immediately after fluid resuscitation in the emergency room to evaluate the extent of their abdominal injury. The subjects were divided into 2 groups. The first group consisted of patients with anemia and the second group consisted of patients without anemia (the control). The following variables were then analyzed in each of the 2 groups: background, physiological data, incidence of blood transfusion, diameter of IVC, abdominal aorta (Ao), and IVC/Ao ratio. RESULTS: The diameter of IVC and the IVC/Ao ratio in the anemia group were significantly smaller than those of the control group. The heart rate, injury severity score, and incidence of transfusion in the anemia group were significantly greater in comparison to those of the control group. Using a multiple logistic regression analysis, the diameter of IVC (odds ratio, 0.375; 95% confidence interval, 0.168-0.839; P = 0.01) was found to be an isolated factor independently associated with the development of anemia. CONCLUSIONS: To predict the development of anemia, the measurement of the IVC for blunt-injured children may be a useful modality.

Clinical features of temporal tip epidural hematomas.

OBJECT: The purpose of this paper was to clarify the clinical features of temporal tip epidural hematomas (EDHs). METHODS: A retrospective chart review was conducted for 53 patients who had suffered an EDH. They were divided into two groups, those whose hematoma occurred in the temporal tip (23 patients) and others (30 patients). The following variables were analyzed: age, sex, Glasgow Coma Scale score, systolic blood pressure on admission, Injury Severity Score, incidence of hematomas in intracerebral regions, location of skull fracture, incidence of cranial nerve injury, type of operation, and Glasgow Outcome Scale (GOS) score at 3 months postinjury. RESULTS: A greater incidence of zygomatic arch or lateral orbital cavity fracture was found in the "temporal tip" group than in the "other" group. There was a greater incidence of cranial nerve injury in the temporal tip (26.0%) than in the other group (6.6%; p < 0.05). Surgery to treat the EDH was more frequently performed in the other group (36.6%) than in the temporal tip group (two patients, 8.6%; p = 0.01). There were no significant differences between the groups in terms of the GOS score. CONCLUSIONS: A temporal tip hematoma is not a rare injury among patients with EDHs. This hematoma tends to be induced by lateral orbital cavity and/or zygomatic arch fractures. It tends to be associated with cranial nerve injury, but it rarely requires an operation. The outcome of patients with this hematoma depends on the associated intracerebral lesions, thus indicating it to be similar to an EDH in other places.

Arterial base excess after CPR: the relationship to CPR duration and the characteristics related to outcome.

OBJECTIVE: We aimed (1) to determine the relationship between arterial base excess (BE) immediately after the restoration of spontaneous circulation (ROSC) and duration of cardiopulmonary resuscitation (CPR) and (2) to ascertain the value of admission BE data as a predictor of mortality in patients resuscitated from cardiac arrest (CA). DESIGN: Retrospective chart review. SETTING: An emergency department of a teaching hospital. PATIENTS: Eighty-seven patients who presented with non-traumatic out-of-hospital witnessed CA between January 2001 and December 2004 in whom arterial blood gas (ABG) analysis was performed within 10 min after ROSC. MEASUREMENTS AND MAIN RESULTS: Individual medical records were reviewed for demographic characteristics; cause of CA; electrocardiogram pattern at the scene; CPR duration; ABG data; outcome (survival to discharge or in-hospital death). Significant correlations were observed between CPR duration and BE in all 87 patients (r = 0.51, p < 0.01) and in the 66 non-survivors (r = 0.46, p < 0.01), but not in the 21 survivors. Mean arterial BE in survivors was significantly higher than that observed in non-survivors (-15.3 +/- 5.7 mmol/L versus -19.1 +/- 6.3 mmol/L). Mean CPR duration was 34 +/- 16 min in non-survivors and 18 +/- 10 min in survivors (p<0.01). Multivariate logistic analysis showed that significant predictors of survival included cardiac aetiology (odds ratio, 6.3; 95% confidence interval, 1.2-33; p<0.01), ventricular fibrillation at the scene (odds ratio, 7.4; 95% confidence interval, 1.4-39.9; p<0.01), and CPR duration

Recovery from a psychotropic drug overdose tends to depend on the time from ingestion to arrival, the Glasgow Coma Scale, and a sign of circulatory insufficiency on arrival.

PURPOSE: The aim of this study was to investigate which factors on arrival correlate with the duration of unconsciousness induced by a psychotropic drug overdose. BASIC PROCEDURE: Patients were 175 consecutive intubated patients unconscious due to psychotropic drug overdose. They were divided into 2 groups, an "early" group in which the patients were extubated within 2 days from hospitalization, and a "delayed" group who were not extubated within 2 days. MAIN FINDINGS: Glasgow Coma Scale (P = .001) scores in the early group were higher than those in the delayed group. The estimated time from ingestion to admission (P < .0001), creatine kinase level (P < .01), number of cases demonstrating shock (P < .05), shock index (P < .0001), and heart rate (P = .001) in the early group were smaller than those in the delayed group. Two subjects in the delayed group died of pneumonia and pulmonary embolism. PRINCIPAL CONCLUSIONS: Delayed arrival from ingestion, a low level of unconsciousness, and a sign of circulatory insufficiency in a patient with a psychotropic drug overdose were risk factors of a delayed recovery and death.