Drowning

Def. : it is a form of violent asphyxia in which the passage of the air to the lung is prevented by submersion of the mouth and nostrils under water or other fluid media.

classification:
1- Typical drowning drowning 2- Atypical

1- Typical drowning :

it is also known as " wet drowning " - it indicates obstruction of the air passage and the lung by inhalation of fluid . typical signs of drowning are present in autopsy. - when water inhaled , the victim gets severe chest pain. Different pathophysiological changes occur when fresh or salt water is inhaled. - in fresh water drowning: - Large amount of water crosses the alveolar membrane into the circulation. - this produces hypervolaemia and dilution of the blood ( 50% dilution occurs within 2-3 minutes),swelling of RBCs with subsequent haemolysis and liberation of potassium. - the heart is therefore submitted to the effect of anoxia,hypervolemia,potassium excess and sodium deficit.Ventricular fibrillation occurs causing death in about 4-5 minutes. - in salt water drowning: the marked hypertonicity of the inhaled water causes loss of fluid from the circulation into the lungs.this gives rise to: - fulminating pulmonary oedema. - progressive hypovolemia,circulatory shock,cardiac failure and standstill. the heart is dilated and death occurs within 8-12 minutes.

2- Atypical drowning:
it indicates conditions in which there is very little or no inhalation of water in the air passage . it includes:
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a- dry drowning. b- immersion syndrome. c- submersion of an unconscious person. d- secondary drowning ( near drowning ). none of the typical signs of downing is present at autopsy. a- dry drowning : - in this condition ,the mere entrance of water into the nasopharynx or larynx triggers intense laryngeal spasm.This spasm allows little or no water to enter the air passage or lungs , and death may result from asphyxia. - This type of drowning is the best one responding for resuscitation measures. b- immersion syndrome :(hydrocution) it results from sudden impact with very cold water where reflex vagal inhibition of the heart causes death from cardiac arrest. c- submersion of the unconscious person: this is possible in the following conditions: - epilepsy , coronary heart disease , drunkenness , occurence of head injury during the fall into water, rupture of cerebral aneurysm and onset of cerebral haemorrhage. - these conditions cause abrupt coma or collapse, in such cases ,complete pictures of death by drowning are not found i.e balloning of the lungs may be absent and the formation of foam may be negligible. d- Secondary drowning syndrome ( Near drowning ) : this may occur in a victim rescued from the water. It may be the result of: A profound reaction mainly due to infection from contaminants in the inhaled water causing lung complications . in addition , oxygen lack, tired heart and cererbral oedema all are causes of deaths . After apparent improvement of the victim by responding to resuscitation measures , this condition may suddenly deteriorate within hours.The victim may suffer from restlessness,increasing pulse and respiratory rates , chest pain ,cough,and cyanosis (rapidly developing pulmonary oedema). If such victim is untreated, there is usually haemoptysis ,
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death from the combined effects of pulmonary oedema and aspiration pneumonitis usually .

Causes of death :
1- Asphyxia is the most common cause of death from drowning . it results from: a. obstruction of the air passage by inhalation of the fluid. b. Laryngeal spasm due to entry of water in the nasopharynx or larynx. 2- In fresh water drowning , death may result from ventricular fibrillation. 3- Heart failure due to drowning in salt water. 4- Vagal inhibition of the heart due to sudden impact with cold water. 5- Other causes: concussion or injury to any vital organ during falling into the water. cardiac failure due to an old heart lesion , especially coronary atheroma or from exhaustion. These are the signs of asphyxia unless death occurred from other causes. The typical appearance is seen only in recent deaths , but when putrefaction advances , signs are masked or entirely obliterated . I) EXTERNAL SIGNS : A Sure external signs: These include 2 signs of greatest importance : 1 ) Fine froth at the mouth and nose: It is fine, white ( or rarely blood stained) , odourless , abundant and increase in amount with chest compression. N.B.:Froth of putrefaction is coarse ,bloody and offensive. Mechanism of formation of froth : During submersion of mouth and nostrils under water,the victim exerts violent attempts to breathe.While some air is inhaled , water passes also into the mouth to be swallowed to the stomach and may be aspirated into the air passage leading to violent coughing . Respiratory efforts continue leading to filling of the air passage and lungs with water. Water in the air passage acts as an irritant and stimulates the secretion of mucus . water ,respiratory mucus and air all
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Postmortem picture :

form the fine froth,which blocks the air vesicles. 2 ) Cadaveric spasm of the hand : As in all cases of rapid asphyxia ,convulsions or at least spasm of groups of muscles is found.Commonly it affects muscles of the hand leading to the presence of weeds and mud in the tightly clenched hand. B Probable external signs: 1- The skin is wet ,cold, clammy and pale due to contraction of its blood vessels. 2-Washer women`s hands.Hands are wrinkled bleached and sodden like the washer women hands due to loss of skin tone ( after submersion in water for 12-18 hours). 3- goose skin or cutis anserine.the skin appears granular and puckered with erection of hair due to spasm of the erector pilae muscles. 4- the epidermis of the hands and feet gets separated in the form of gloves and stocking after 2 weeks. 5- hypostasis is seen in the upper half of the body ( head, neck and shoulders)as it is the most dependent part of the body. 6- Other external signs of asphyxia are present ( if it is the cause of death). 7- post mortem wounds may be found and are caused by fishes or propellers of ships. N.B: Rigors mortis appears early due to the muscular exhaustion.. Cooling of the body takes half the time which is taken in the air. Floating of the body usually occurs after 5-8 days in summer and after double that time in winter.

floatation depends on: 1- rate of putrefaction. 2Specific gravity of the body ( fatty bodies foloat earlier). 3Nature of the water: it occurs earlier in salty water than in fresh water. putrefaction is delayed, but it starts
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immediately after extraction of the body from water. In case of prolonged submersion under water ,adipocere formation sets in. II) INTERNAL SIGNS: All internal signs are sure signs of drowning. 1General internal signs of asphyxia ( if it is the cause of death). 2Water may be found in the middle ear due to violent respiratory efforts. 3Changes in the respiratory tracts: The respiratory passage usually contains fine white froth,inhaled foreign material as algae , weed, mud ,sand and regurgitated stomach contents. The mucus lining is congested. The lungs are: (a) voluminous and show the impression of ribs upon them. (b) The surface is pale and pits on pressure. (c) On cut section ,blood stained frothy fluid streams away from the cut surface. (d) Subpleural tardieu and silvery spots are seen. 4Changes in the heart :the right side of the heart and large veins are distended with dark red blood with subpericardial haemorrhage. 5Biochemical changes in the blood: In fresh water drowning ,water passes into the blood leading to haemodilution and decreased its viscosity.there is red blood cells lysis with liberation of potassium and diminished chloride content of the blood in the left side of
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the heart. In salt water drowning ,water passes out of the capillaries to the lungs alveoli leading to haemoconcentration ,increased blood viscosity and crenation of red red blood leading to elevation of their concentration in the left side of the heart. 6water in stomach and intestine: unpalatable water (salty or muddy) is present in the GIT. water from the medium of drowning is swallowed by the victim during his struggle for life.It carries the criteria of water in which the victim was drowned. Peristaltic movement may push the swallowed water to the small intestine. it is an absolute proof for death from drowning provided that the victim did not drink it before drowning. 7diatoms in tissues: most natural water contains diatoms which are a class of microscopic unicellular algae suspended in water. It has a siliceous cell wall which resists acid digestion and putrefaction. When the diatoms are inhaled with water into the lungs of a drowned still living body ,they will be transported with the circulatory blood to body tissues especially the brain and bone marrow. Diagnosis of drowning in putrefied bodies: presence of aquatic weeds,mud or sand in the air passage may be the only sign of drowning. The lungs are decomposed and their water content passes into the pleural and the peritoneal cavities .
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Microscopic demonstration of plankton and diatoms in brain and bone marrow.

Time passed since drowning

1- Rate of cooling. 2- Rigor mortis sets in early. 3- Floating of the body. 4- Wrinkling of the skin of hands and feet. It begins after 12 hours,becomes definite after 18 hours and completes within 24 hours. 5- Epidermis of the skin of hands and feet becomes loose and peels like gloves and stocking after about 2 weeks.