2. Objectives
1. Drowning definition
2. Types of drowning
3. Process of drowning
4. Pathophysiology of drowning.
5. Postmortem findings
6. Cause of death
3. • Drowning is a form of asphyxia due to aspiration of fluid into air-
passages, caused by submersion in water or other fluid.
• Complete submersion is not necessary.
• About 1,50,000 person die from drowning each year around the world.
4. Types:
Drowning is of five types:
(1) Wet drowning ( typical drowning )
And ( Atypical )
(2) Dry drowning
(3) Secondary drowning (post- immersion syndrome or near drowning)
(4) Immersion syndrome (hydrocution or submersion inhibition)
(5) Submersion of the unconscious
5.
6. The process of drowning was divided into five stages. (Brouardel)
(I) The stage of surprise lasting for 5 to 10 seconds.
(2) The first stage of respiratory arrest, lasting for about one minute.
(3) The stage of deep respiration, lasting for about one minute.
(4) The second stage of respiratory arrest, lasting for about one minute.
• Thoracic movements were not observed.
• The corneal reflex was lost and pupils were widely dilated.
(5) The stage of terminal gasps, lasting for about 30 seconds.
7. The pulmonary alveolar lining is semi-permeable.
• If water enters the alveoli, an exchange of water takes place through
the alveolar lining.
• The extent and direction of these change depends on the difference
between the osmotic pressure of the blood and the water.
9. Drowning in Fresh Water or Brackish Water :
(1) In drowning in fresh water (0.6% NaCI)
(2) 2 ½ litres, water may be inhaled and absorbed in three minutes;
(3) blood volume may increase by 50% strain on the heart due to
hypervolaemia.
• Haemodilution leads to haemolysis,
• relative anaemia,
• myocardial hypoxia,
• haemoglobinaemia, and haemoglobinuria,
• marked hyponatraemia and hyperkalaemia.
10. 5) Calcium levels may fall to 2 mEq/L.
6) Fresh water alters or denature the protective surfactant which lines the
alveolar wall, while sea water dilutes or washes it away.
7) The denaturing of surfactant can continue afterwards also….
8) Loss or inactivation of pulmonary surfactant (lipoprotein) and alveolar
collapse decrease lung compliance
severe ventilation perfusion mismatch
11. • The defective functioning of surfactant pulmonary oedema with
transudation of protein-rich fluid into the alveolar spaces, hypoxia and
secondary metabolic acidosis.
• Acute respiratory distress syndrome (ARDS) due to aspiration if the person
survives.
• Severe hypotension may occur during and after the initial resuscitation
period.
12. • Debris plugging the patient's airway and release of inflammatory
mediators.
• (sodium and calcium)
• potassium (a powerful myocardial toxin)
• Cardiac arrhythmias leading to ventricular tachycardia and fibrillation .
13. • Fresh water drowning(hypotonic)
Hemodilution
Volume of
blood ↑
Heart
overload
ventricular
fibrillation
Dilution of the
plasma
Rupture of RBC
Release of
potassium
hyperkalemia
Heart failure Death
14. (2) Drowning in Sea Water :
Due to the high salinity of sea water ( three percent NaCI),
water is drawn from the blood into the lung tissue, and produces
severe pulmonary oedema, and hypernatraemia.
This causes haemoconcentration.
Re-establish osmotic balance, salts from the water in the lungs pass
into the blood stream
15. • A marked bradycardia occurs, plasma sodium level.
• Heart failure may occur due to myocardial anoxia and increased
viscosity of blood.
• The red cells are crenated in sea water drowning.
• Slow death occurs from asphyxia.
16. • Sea water drowning(hypertonic)
hemoconcentration
hypovolemia
Pulmonary edema
Circulatory shock
Heart failure/asystole
Death
17. Postmortem findings
External findings
a. General
• Wet clothes and skin, cold, moist, pale if body removed recently from water
• Postmortem lividity usually found on the face.
• The upper part of chest, hands, lower arms, feet.
• In turbulent water where the body is in continuous movement, then post mortem
lividity may not develop at all.
• Postmortem staining is light pink in colour.
18. b. Froth
A fine, white, lathery froth or foam is seen at the mouth and nostrils
Characteristic external sign of drowning
Water irritates mucous membrane secrets large quantities of tenacious mucus.
Forth consists of protein and water.
Most common in sea water drowning
If wiped away, it gradually reappears, especially if pressure is applied on the
chest.
20. c. Cutis anserina or goose skin or goose flesh
• Skin has granular and puckered appearance.
• Seen in anterior surfaces of the body particularly on the thighs
• Produced by spasm of the erector pilae muscles attached to each hair
follicle
21. d. Cadaveric spasm
• Weeds, gravel, grass, sticks, twigs, leaves, etc present in
the water may be firmly grasped in the hands due to
cadaveric spasm.
• Strongly suggest that person was alive when he drowned.
• Indicate sign of struggle for his life.
22. e. Washer woman’s hand
• Wrinkling of the skin begins to appear shortly after immersion, bleaching of
epidermis in four to eight hours, and the bleached, wrinkled and white in colour.
23. INTERNAL FINDING
A. Lungs
• Voluminous( ballooning)
• May completely cover the pericardial sac
• Bulge out of the chest when sternum is removed.
• Froth is present in secondary bronchi
24. EMPHYSEMAAQUOSUM
• Hyper-expanded and water-logged lungs . Ribs imprints may be present
on the surface of lungs
OEDEMAAQUOSUM
• Unconscious victim
• Flooding of the lungs with water
• Without formation of column of froth
SUB-PLEURAL HEAMORRHAGES (PAULTAUF SPOTS) :
• In 5-60% of drowning reflecting intra-alveolar haemorrhages
25.
26. LUNGS FINDING :
s.no Trait Fresh water drowning Sea water drowning
1 Size and weight Ballooned but light Ballooned and heavy
2 colour Pale pink Purplish and bluish
3 Consistency Ephysematous Soft and jelly like
4 Shape after removal from
the body
Retained, do not collapse Not retained ,tend to flatten out
5 Sectioning Crepitus is heard . Little
froth and no fluid
No crepitus, copious fluid and froth
27. B. Stomach
• Content water in 70% cases
C. Brain
• Congested, swollen with flattening of gyri
D. Other
• Organs Congested
• Haemorrhage in temporal bone or in the mastoid air cell, seen in large
cases
28. Autopsy signs of drowning (seen in 35% of cases)
1. Froth in nose and mouth
2. Pulmonary edema
3. Overdistention of lungs
4. Dry drowning
5. Middle ear hemorrhage
6. Chemical tests (unreliable)
29. SPECIFIC SIGNS
• SIGN OF KRUSHEVSKY: full of small bubbles white foam in respiratory
tracts
• SPOTS OF RASSKAZOV-LUKOMSKY or Paltauf Macules : reddening
and edema of mucous tunic of respiratory tracts, increasing and
emphysema of lungs, pale, dim hemorrhages on their surface
30. SIGN OF МОRO: presence of water in a small intestine and abdominal
cavity
• SIGN OF SVESHNIKOV:
• presence of liquid of drowning environment in the sinus of sphenoid
• increasing of liver in size and presence of plankton in inner organs
• Sabinsky-Orahovatz sign- Spleen becomes anaemic .
32. Causes of Death:
(I) Asphyxia: Inhalation of fluid causes obstruction to the air-passages.
Circulatory and respiratory failure occur simultaneously, due to
anoxia.
(2) Ventricular fibrillation:
In fresh water drowning death may occur in three to five minutes from a
combination of anoxia, and a disturbed sodium potasium ratio producing
arrhythmias of the heart beat, ventricular tachycardia and fibrillation.
(3) Laryngeal spasm may result from inrush of water into the
nasopharynx or larynx.
33. (4) Vagal inhibition is due to icy cold water, drunkenness, high emotion or
excitement (intending suicides) and unexpected immersion.
(5) Exhaustion.
(6) Injuries : Fracture of skull and fracture-dislocation of cervical vertebrae
may occur due to the head striking forcibly against some solid object.
Concussion may occur due to striking the head against some hard substance,
or the water itself while falling from a height.
Fatal Period: Death usually occurs in 4-5 minutes of complete submersion in
fresh water and 8 to 10 minutes in sea water
34. DIAGNOSIS
• All test are unreliable
• Autopsy diagnosis of drowning can pose problems, because the
findings are often minimal, obscure or completely absent.
• Drowning is one of the most difficult modes of death to prove at
postmortem, especially when the body is not examined in a fresh
condition
