DEATH DUE TO DROWNING

Definition
Drowning is defined as the entry or aspiration of fluid through the nose and mouth into the respiratory tract. The definition excludes aspiration of vomit, blood, saliva, bile, or meconium Drowning is death from suffocation (asphyxia) caused by a liquid entering the lungs and preventing the absorption of oxygen leading to cerebral hypoxia andmyocardial infarction.

Introduction:Finding a body in water poses a challenge for the pathologist and other investigators determining the cause and manner of death. All manners of death are possible. Drowning is one of the leading causes of death associated with an undetermined manner. Information about the circumstances preceding the drowningi.e., how the victim became submergedare lacking in many cases, because the events prior to submersion are unwitnessed. Witnesses were present in one-half to three-fourths of drownings in some series. The majority of submerged bodies, including those of undetermined manner, have been classified as drowning. The postmortem diagnosis of drowning requires exclusion of these other possibilities, with the realization that during the agonal stages of natural and other types of unnatural deaths, aspiration of water does occur. Despite the paucity of postmortem findings, drowning involves complex pathophysiological mechanisms dependent on the various factors related to the victim and the scene.

MECHANISMS OF DEATH FROM WATER SUBMERSION

The usual drowning sequence of a conscious victim involves panic, apnea, swallowing of water, unconsciousness, reflex gasping with aspiration, airway foam production, convulsions, and death with or without reflex regurgitation of gastric contents .

Drowning (Wet Drowning, Classical Drowning)

Wet drowning occurs in about 80 to 90% of cases. Complete submersion is not necessary for drowning to occur. An intoxicated, unconscious, epileptic, or very young individual can drown in as little as 5 to 6 cm (2 in.) of water, if fluid covers the mouth and nose. The major consequence of drowning is hypoxia. The volume and composition of the drowning medium determine the pathophysiological mechanisms leading to hypoxia and eventual cardiac arrest.

Immersion in Cold Water

Sudden immersion in cold water can initiate cardiorespiratory reflexes lastingabout 2 to 3 min. A rapid decrease in skin temperature directly stimulates the respiratory drive through afferents from peripheral cold receptors and reaches a maximum in water at about 10C (50F). The response can be heightened in a lightly clothed individual. Further reducing the temperature to 0C (32F) does not increase the magnitude of the response. The initial cardiovascular response reflects sympathetic activation and is characterized by peripheral vasoconstriction, tachycardia, and increased cardiac output .Increased heart workload and catecholamine levels can result in arrhythmias, particularly in older victims with cardiovascular disease. Complete submersion in cold water following breathholding can increase the frequency of supraventricular arrhythmia.

EXTERNAL EXAMINATION
Froth (meringue-like) is expressed around the mouth and nostrils in a typical wet drowning. Froth can be washed away by the action of water before body retrieval, disappear after the body has been in the open, or removed before transfer of the body for autopsy. Froth may be not seen by investigators at the scene. In one study, external foam was observed in only 19% of cases.

Facial or scalp blunt trauma means ruling out underlying cranial and cervical spine trauma; however, cutaneous injuries are possible when the victim assumes a head-down position and scrapes the bottom . The absence of external trauma in an unwitnessed submersion does not mean that drowning is the cause of death.

INTERNAL EXAMINATION
Pleural Effusions
A total of 80 mL or more of pleural fluid (i.e.,40 mL in each pleural cavity) is found in nondrowning cases (e.g., intoxication, strangulation, smothering, stabbing. The origin of the pleural fluid could result from disease, if the autopsy reveals underlying cardiac abnormality (e.g., myocardial hypertrophy or scarring. A combined weight of the lungs and pleural effusions between 1000 and 2200 g was observed in more than three-fourths of cases having a submersion interval of less than 30 d and assisted the diagnosis of drowning. There was no significant difference in the actual amount of fluid seen in fresh and salt water drownings in another study (fresh water, 521 340 mL; salt water, 768 536 mL). About two-thirds of seawater and onethird of freshwater drownings showing no or early decomposition (i.e., skin maceration) had increased pleural fluid. In another study, a slightly higher proportion (38%) of seawater drownings had effusions, compared with freshwater cases (33%). There was no correlation found between total lung weights and pleural fluid amount in fresh and saltwater drownings. Average lung weights, with or without an increase in pleural fluid, were 1326 436 g and 1310 358 g, respectively. In drowning and nondrowning cases retrieved from water, the total amount of pleural effusion increases with decomposition owing to passive seepage of the drowning medium into the chest but decreases with advanced decomposition. Levels of more than 250 mL in decomposed bodies may favor drowning. The time interval between body recovery and autopsy has no bearing on the amount of pleural effusion. Large amounts of pleural fluid can accumulate even after a short submersion interval, but significantly more cases, submerged 8 or more hours, have effusions (67 vs 39% < 8 h). A short submersion interval (20 min) has been associated with effusions. There are no differences in the amounts of pleural fluid based on sex, body weight and length, and heart weight. There is no correlation between blood ethanol concentration and amount of pleural fluid.

Lungs
Pulmonary edema is not specific to drowning and is seen in natural (e.g., heart disease) and other unnatural deaths (e.g., acute opiate intoxication, epilepsy). Lung findings must be correlated with circumstances. Voluminous or overinflated congested lungs are seen in wet drownings. Lungs can bulge from opened thorax, and rib markings are seen on the pleural surface. Dependent congestion suggests a postmortem finding. Petechiae may be seen on the visceral pleura. Superficial bullae (subpleural emphysema) are sometimes observed. Frothy fluid (edema) is expressed from the cut surface of the lungs. A minimum total lung weight of 1000 g in adults (>18 yr) is significant in distinguishing between drowning and nondrowning cases; however, this cut-off weight may be arbitrary with the realization that variable amounts of water are inhaled. Other studies have shown: Combined weight of lungs 1411 (avg.) 396.4 g in drowning; 994 133.0 g in 20 controls (age >18 yr; time interval in water <24 h; controls, gunshot wound to head). Combined weight of lungs about 1400 g (avg.); 780 g in 50 controls (age >18 yr; controls, gunshot to head). No difference in lung weights between fresh and saltwater drownings has been observed. Frothy fluid, which can be blood-tinged, is seen in the larynx, trachea, and bronchi. This is an antemortem reaction. Froth is an admixture of edema fluid, surfactant, and bronchial secretion. Edema fluid in freshwater drowning tends to be bloody because the hypotonic medium ruptures red blood cells. In saltwater drowning, red blood cells tend to retain their integrity. The diagnosis of drowning may be more tenuous without the presence of froth. Foreign material from the drowning medium may be observed in the upper respiratory tract and lung parenchyma, but finding water or debris in the mouth or upper airway is not sufficient to diagnose drowning. Froth can be seen after only a few minutes of immersion. Froth disappears as the postmortem interval increases.

Other Organ Weights

If the recovery time of a body is shorti.e., within 6 h of deaththen certain organ weights may be increased in asphyxiation and drowning cases relative to other types of trauma. In one study, the effects of asphyxiation increased the mean organ weights for the lungs, kidneys, liver, and spleen compared with trauma deaths. Mean heart and brain weights remained the same in the trauma, asphyxia, and drowning cases. Prolonged submersion can reduce organ weights. Small anemic spleens have been observed in drownings, but considerable overlap exists in the range of weights when compared with controls. Sympathetic stimulation with organ contraction is a proposed mechanism. Histological evaluation of the quantity of blood in the splenic sinuses reveals no differences. The autopsy finding of a small, anemic spleen in drowning is likely a postmortem change caused by prolonged submersion.

Gastrointestinal Tract
Fluid and foreign material from medium can be found in the stomach and intestines as a result of swallowing; however, small amounts of water can enter the stomach after death particularly if the pressure of the drowning medium is high. During the interval of submersed breathing, the victim may vomit and when a considerable amount of water is gulped, stomach contents may be found in the air passages.The stomach plays a relatively passive role in the vomiting process, because the major ejection force is made by the abdominal musculature. With relaxation of the gastric fundus and gastroesophageal sphincter, a sharp increase in intra abdominal pressure is brought about by forceful contraction of the diaphragm and abdominal wall muscles. This, together with the concomitant annular contraction of the gastric pylorus, results in the expulsion of gastric contents. The process of vomiting, if forceful, may lead to pressure rupture of the esophagus linear mucosa tears in the region of the cardioesophageal junction. The account of liquid in the stomach ranged between 30 and 750 cm3. In two cases, having previously suffered road accident with posterior precipitation into the water, bone marrow pulmonary trombi were appreciated. In the remaining cases, evidence of external or internal traumatic injuries was minimal and in most of cases was absent. Subsequent histological examination of gastric lesions revealed that detachment of the stomach layers (the clivage level) occurs in the deep submucosa. The blood vessels of submucous plexus were stuck to the superficial portion and in the subjacent zone a light layer of collagen fibers was stuck to muscularis propia.

Cranial Findings in Drowning

Middle ear and mastoid congestion/hemorrhage are manifest as blue discoloration of the petrous bones after stripping the dura. This finding is not seen in all cases and occurs at a minimum water depth of about 75 cm (2.5 ft). Middle ear hemorrhage is thought to arise because a pressure differential between the middle ear and the environment caused by blockage of the Eustachian tubes by water. Prior scarring from otitis media and a lack of pneumatization of the mastoid air cells are factors that decrease the likelihood of hemorrhage. Middle ear congestion/hemorrhage may be an indicator that the victim was alive at time of submersion and could explain why experienced swimmers develop difficulties due to disequilibrium. Alternatively, this finding may be a postmortem change owing to a head-down position. Aspiration of sanguinous watery fluid from the sinuses (e.g., sphenoid sinus) may also be an indicator of drowning.

References
1. J. Michael Shkrum & David A. Ramsay (2007). FORENSIC PATHOLOGY OF TRAUMA;Common Problems for the Pathologist, ch# 4, pages 211-228 2. Jerome Imburg and Thomas C. Hartney. DROWNING AND THE TREATMENT OF NONFATAL SUBMERSION: I. 1966. 3. J. Blanco Pampna, S.A. Garca Rivero, Noem M. Tamayo, R. Hinojal Fonseca, (2004). Gastric mucosa lesions in drowning: its usefulness in forensic pathology.