Drowning

Dr. Rijen Shrestha27-04-2068

PRESENTATION ON BODY RECOVERED

FROM WATER

TopicsPhysiology of immersion

Drowning

Investigation into the causes of Death

Epidemiology

PHYSIOLOGY

P h y s i o l o g i c a l c h a n g e s

Diving reflex:

Exposure of face to cold water stimulates trigeminal nerve which transmits the afferent impulse to the medullary centers in the brain, results in bradycardia, systemic hypertension and shunting of blood from cutaneous and splanchnic vessels to the heart and the brain.

Continued…..This reflex slows the heartbeat, constricts

peripheral arteries thereby directing more oxygenated blood to the heart and brain, and produces immediate apnoea that prevents aspiration.

Continued…….

Respiratory and cardiac metabolism decreases, which in turn reduces the damage to organs. In some cases, children who have been submerged for extended time periods can be fully resuscitated. ( It is recorded that successful resuscitation with full recovery was possible even after submersion in cold water for 66 minutes)

All body recovered from water will show signs of immersion irrespective of the cause of death.

Cutis anserina or ‘goose-flesh’Maceration of the skinErratic post-mortem hypostasis.Mud, silt, sand etc on the body.

Estimation of the time of immersion

No wrinkle of the finger pad: few hours

Wrinkled fingers, palms and feet: Half a day to 3 days

Early decomposition, often first in the dependent head and neck, abdomen and thighs: 4-10 days

Continued….

Bloating of face and abdomen with marbling of veins and peeling of epidermis on hands and feet, and slippage of scalp: 2-4 weeks

Gross skin shedding, muscle loose with skeletal exposure, partial liquefaction: 1-2 months

Cutis anserina

It is the pimpling of the skin due to the contraction of the erector pilae muscle attached to hair follicle.

Maceration of the skin

The keratin layer of the skin (hands, feet) becomes wrinkled, pale and sodden. Also called as “washer woman’s skin”.

This is caused by the vasoconstriction of the capillaries and prominence of the ridges present beneath the skin.

Erratic postmortem hypostasisDue to the changing posture of the body in the flowing

water.

Present at the hands, head and legs due to the flotation of the body with hands, head and limbs hanging down with buttocks at uppermost postion.

Mud, silt and sand.

It is not unusual to find mud, silt and sand smeared over the body.

Livor mortis

Post mortem staining is irregularly distributed due to the unstable position of the body.

Often postmortem staining can be noticed at the head and the limbs as these parts lie relatively lower than the other parts.

Rigor mortis

Rigor mortis appears early because struggle inside the water causes rapid depletion of ATP and rigor mortis sets in early.

Confusion between ante mortem and post mortem injuries

Normally the presence of bleeding usually distinguishes ante-mortem from post-mortem injuries.

But ante mortem injuries might appear blood less due to the leaching of blood from the wound by the water.

Also , the head down position of a floating corpse causes passive congestion of the head with blood, so that post- mortem injuries tend to bleed, creating the diagnostic confusion.

Drowning

Defi nition of drowning(WHO)

“Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid. Drowning outcomes are classified as death, morbidity and no morbidity”.

Definition of drowning from standard text book Drowning is a form of violent asphyxial death where in

the entry of air into the lungs is prevented by water or other fluids due to the submersion of mouth and nostril.

The mechanism of death is complex and is not simply an asphyxiation due to suffocation.

Mechanism of drowningSubmersion is followed by struggle which subsides

with exhaustion and drowning begins.

When the breath can be held no longer, water is inhaled, with associated coughing and vomiting,

and is rapidly followed by loss of consciousness with death some minutes later.

Mechanism of death in drowningThe mechanism of death in acute drowning is

irreversible cerebral anoxia.

Original concept of death in drowning was due to asphyxia with water occluding the airways.

However experiments and experience suggest various mechanism of death

These are

Cardiac arrhythmias

Electrolyte imbalance

Vagal stimulation

Laryngeal spasm

Types of drowningTypical or wet drowningAtypical drowning

-Dry drowning-immersion syndrome-submersion of unconscious-Secondary drowning (near

drowning syndrome)

Wet drowning

Fig. mechanism of death in wet drowning

Fresh water drowning

Fig. mechanism of death in fresh water drowning

Salt water drowning

Fig. mechanism of death in salt water drowning

Dry drowning

Fig. mechanism of death in dry drowning

Immersion syndrome

Fig. mechanism of death in immersion syndrome

Submersion of unconscious

Therefore typical signs of drowning are absent

Investigation of cause of death in the case of body recovered from water.

The diagnosis of drowning is one of the most difficult in forensic pathology, especially when there is delay in recovering the victim.

When a body is recovered from water, two critical questions require resolution:1. Was the victim alive or dead when he entered the

water?

2. Is the cause of death drowning? (and if not,

what is the cause of death?).

Cause of death could be Natural

Trauma

Intoxication

Drowning

Effects of immersion other than drowning

Combination of above cause

Signs of drowning

Signs of immersion only demonstrate submersion of the body for a period of time but are not signs of drowning.

There are no autopsy findings pathgnomonic of drowning.

Consequently, obtaining proof that the victim was alive on entering the water, and excluding the presence of natural, traumatic and toxicological causes of death, are critically important.

Some pathological changes are characteristic of drowning, but the diagnosis is largely one of exclusion.

A fine, white, froth or foam in the airways and exuding from the mouth and nostrils is characteristic of drowning. (FOAM CAP )

It is a vital phenomenon and indicates that the victim was alive at the time of submersion.

However, similar foam is found in deaths from other causes, e.g. heart failure, drug overdose, and head injury.

Froth at the mouth

Fig. Foam cap

Froth at the nose

Fig. Foam cap

Emphysema aquosum

The lungs are characteristically over-inflated and heavy with fluid. However, this is not invariable and, when present, is not distinguishable from "fluid on the lungs" (pulmonary edema seen in heart failure, drug overdose and head injury).

Fig. Emphysema aquosum

Fig. Cut section of lung showing Pulmonary edema

Diatoms

The diatom are unicellular microscopic algae that lives in water and are ubiquitous in nature. Demonstration of diatoms in drowning victim requires a careful protocol to avoid possible contamination.

Sample collection (cardiac blood, lung, liver, kidney tissue, bone marrow and brain) should be performed during the first part of the autopsy. Sample preparation requires chemical or enzymatic digestion.

The diatom test should be both qualitative and quantitative. Species recovered from the body must correspond to those from the site of drowning and approximately in the same proportions.

The diatom test has poor sensitivity and thus is much debated because it is always difficult to rule out possible contamination. Moreover, a negative diatom test cannot rule out drowning as the cause of death.

The diagnosis of drowning is based on police investigations, forensic autopsy, microscopic analysis, and biochemical tests, but never solely on pathology findings.

Fig. Diatoms

Drowning may not produce extensive findings. In fact, in 10 to 15% of cases, intense laryngospasm may even prevent water from entering the lungs. In the case shown here, a child drowned in a fresh water canal, and some of the plant material in the water was aspirated into a bronchus

It is disputed whether sand, silt, weed, and other foreign matter, found in the airways constitutes proof of immersion during life.

The presence of large quantities of water and debris in the stomach strongly suggests immersion during life.

Conversely, the absence of water in the stomach suggests either rapid death by drowning, or death prior to submersion

Hemorrhages in the boney middle ears are occasionally (some would say commonly) seen in drowning cases.

Such hemorrhages also occur in deaths from other causes, e.g. head trauma, electrocution and mechanical asphyxiation

Fig. Hemorrhages in the middle ears

Epidemiology

In 2000, an estimated 409 272 people drowned, which makes drowning the second leading cause of unintentional injury death globally after road traffic injuries .

This total includes only “accidental drowning and submersion”. The problem is even greater. These Global Burden of Disease (GBD) figures are an underestimate of all drowning deaths, since they exclude drowning due to cataclysms (floods), water and other transport accidents, assaults and suicide.

(WHO report)

Table 1. Global drowning deaths by sex and WHO region (GBD 2000)

World Total AFR AMR EMR EUR SEAR WPR

Males 281 717 67 654 20 181 20 712 30 322 55 258 87 600

Females 127 554 23 311 4 408 6 904 7 196 36 520 49 216

Total 409 272 90 965 24 589 27 616 37 518 91 778 136 816

Sex ratio (M: F) 2.2 : 1 2.9 : 1 4.6 : 1 3 : 1 4.2 : 1 1.5 : 1 1.8 : 1

% 100 22.3 6 6.8 9.1 22.4 33.4

Rate† 6.8 14.2 3 5.7 4.3 6 8.1

AFR = African Region; AMR = Americas Region; EMR = Eastern Mediterranean Region; EUR = European Region; SEAR = South-East Asian Region; WPR = Western Pacific Region † Rate per 100 000 people.

Among the various age groups, children under five years of age have the highest drowning mortality rates worldwide

Drowning is the leading cause of injury death to children aged 1-14 years in China

In Bangladesh, 20% of all deaths in children aged 1-4 years are due to drowning

Drowning in young children is often associated with a lapse in supervision.

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Data of drowning in our department(2062-07-15) TO (2067-07-14)

Total number of cases: 6465

Total number of drowning cases:205

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