DEPARTMENT OF AGADATANTRA

KMCT AYURVEDA MEDICAL

COLLEGE
Mampatta,Manassery PO Kozhikode,Kerala-673602

COMPILATION ON DROWNING
DEVAPRIYA T V
2019 -2020

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 KMCT
AYURVEDA MEDICAL COLLEGE
MANASSERY P.O, KOZHIKODE, KERALA- 673602

DEPARTMENT OF AGADATANTRA
CERTIFICATE
This is to certify that Mr/Miss ……………………………..
Studying in III Professional BAMS has completed compilation
on………………………………………………..
in AGADATANTRA as prescribed by KUHS University during the year
2019-20.

Class no:…………… Reg. No:

……………..

Assistant professor Associate Professor

Professor

Place:………………..
Date:…………………. date of examination:…………

Internal Examiner:…………………………

External Examiner:…………………………

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 ACKNOWLEDGEMENT

I pay obesiance to the almighty with those showers of

blessing this task has ventured without any hinderence.

I hereby express my heartful gratitude to my parents who

are all the forcefront in initiating every work,including
joining this course.

First and foremost I would like to thank Dr.Subhasree G H

(Principal and HOD,Dept.of Agadantara),for her
encouragement and for providing all necessary things.

I acknowledge my sincere gratitude to Dr.Vivek k

(Assistant professor,Dept.of Agadantara) who supported
and guided me in this compilation and studies.

I am also thankful to Dr.Anjana (Assistant

professor,Dept.of Agadantara) who helped me to complete
this compilation and in my studies.

I gratefully remember the very good support and help of

Mr. Shaji Joseph

I would like to extend heart filled thanks to all those great

authors,publishers,commentators etc. whose work has set
the base for compilation.

I would like to thank my seniors who guided us in

completion of this compilation

Without remembering my friends my work and whole

preface become meaningless. Thus support help guide and
encourage my compilation.

Place:Manassery Name:Devapriya T V
Date:01/03/2021

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 INDEX

SL.No Particulars Page.No

1 Introduction 1
2 Drowning 2
3 Incidence 3
4 Mechanism of Drowning 4
5 Causes of death in drowning 6
6 Pathophysiology 7
7 Classification 8
8 Treatment 10
9 Postmortem findings 11
10 Diagnosis 17
11 Medicolegal aspects 18
12 Directions to the investigating 19
officers
13 Laws applied in drowning accident 20
cases

14 Drowning sum-up 21
15 Epidemiology 22
16 Conclusion 23
17 Reference 24

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 INTRODUCTION

Mechanical Asphyxia is a broad term in which enough

external pressure is applied to neck,chest or other areas of
body or the body is positioned in such a way that
respiration is difficult or impossible.

Types

1.Closure of external respiratory orifices by hand,mouth or

any other substance. Eg:smothering
2.Closure of air passage by external pressure on neck.
Eg:Hanging,Strangulation,Throtting
3.Closure of air passage by impaction of foreign bodies in
larynx/pharynx. Eg:Chocking
4.Prevention of air passing due to air passing being filled
with fluid. Eg:Drowning
5.External compression of chest and abdominal walls
interfering with respiratory movement. Eg:Traumatic
Asphyxia

Drowning is the process of experiencing respiratory

impairment from submersion or immersion in liquid.
• Implicit in this definition is that a liquid-air interface is
present at the entrance to victims airway which
prevent the victim from breathing O2.
• Outcome may include delayed morbidity,delayed or
rapid death,life without morbidity.
• Term drowning was previously defined as immediate
death secondary to asphyxia while immersed in a
liquid,usually water or within 24 hrs of submersion. The
definition exclude aspiration of vomit,blood,saliva,bile
or meconium

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 DROWNING

Drowning is the form of violent mechanical asphyxia due to

the aspiration of fluid into air passage caused by
submersion in water or other fluid .Complete submersion is
not necessary for death but the submersion of nose &
mouth alone for sufficient period can cause death from
drowning.

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 INCIDENCE

• About 15,000 person die from from drowning each

year around the world .
• Drowning victim are predominantly male
• It occurs in summer month more frequently seen in
rivers,ponds and lakes
• The age group affected are children(<4yrs) and young
adults(15-24 yrs).Drugs and alcohol abuse among
teenagers are other associated factors.

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 MECHANISM OF DROWNING

• When a person falls in to the water,he sinks partly due

to the falling force and partly due to specific gravity
which is 1.08.Shortly afterwards he rises to the surface
due to natural buoyancy of the body .In sudden
immersion into the water the victim may take deep
inhalation of water.
• He may hold his breath for varying period until the CO 2
in blood and tissue reaches sufficient levels to
stimulate the respiratory center. At that time inevitable
inhalation of water may occur.
• When cries for help and struggles,he is likely to inhale
water,which produce coughing and drives out large
volume of air out of lungs and lead to disturbance of
rhythm of breathing
• He may aspirate some gastric contents and vomitus.
• His struggle may increase and again sinks .If this
occurs during inspiration, he inhale more water.

Position of a submerged dead body.

• Consciousness often lost within 3 minutes of

submersion. Convulsive movement then occur followed
by coma or suspended animation or death in case of
warm water.
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• Immersion in cold water may be followed by
immediate circulatory collapse, irregularity of
heartbeat and then death
• In freezing water death occurs in 5 to 10 minutes.
• At 6oc incapacitation is likely to occur within 30
minutes and death less than in 1 hr.
• A body fresh in water usually sinks to the bottom but
float over several meters under the surface of water
depending upon the salinity

Mechanism of death in
fresh water drowning

Mechanism of death in sea

water drowning

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 CAUSES OF DEATH

1-Asphyxia:Due to anoxia of both myocardium and

respiratory center, respiratory and circulatory failure occur
simultaneously

2-Ventricular fibrillation:In fresh water drowning death

occur in 3 to 5 min from a combination of anoxia

3-Laryngeal spasm: It may result from in rush of water

into he nasopharynx and larynx

4-Vagal inhibition:Due to icy cold water,drunkness,high

emotion or excitement

5-Exhaustion

6-Injuries

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 PATHOPHYSIOLOGY

The pulmonary alveolar lining is semipermeable. The

extend of exchange of fluid between blood and alveoli
depends on osmotic pressure gradient.

(i)Drowning in fresh/brackish water

This water denature the protective surfectant which in turn
decrease lung compliance,resulting in severe ventilation
perfusion mismatch and also the transudation of the
protein rich fluid into the alveolar spaces. Acute
respiratory distress syndrome may result due to
aspiration if the person survives. Cardiac arrhythmia
leading to Ventricular tachycardia and fibrillation occur
die to hypoxia & Haemo dilution.

(ii)Drowning in sea water

Due to high salinity of sea water,water is drawn from blood
into lung tissue and produce Severe pulmonary edema
& hyper natrimea. A marked Bradycardia occurs. Heart
failure may occur due to myocardial anoxia and increased
viscosity of blood.

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 CLASSIFICATION
DROWNING

PRIMARY/TYPICAL/ ATYPICAL
WET DROWNING DROWNING
1.Fresh water drowning 1.Dry drowning
2.Salt water drowning 2.Immersion
syndrome
3.Secondary
drowning
4.Shallow water
drowning

1.TYPICAL/WET DROWNING
Water inhaled into the lungs and victim has severe chest
pain

(a)Fresh water drowning

The aspirated water is rapidly absorbed from the alveoli
into the circulation leading to haemodilution and
haemolysis.

(b)Sea water drowning

The aspiration of water result in the withdrawal of water
from the pulmonary circulation into the alveolar space.

2.ATYPICAL DROWNING
(a)Dry drowning
• Water does not enter the lung due to the laryngeal
spasm induced by small amount of water entering in
the lungs
• Seen in 1 to 2% of cases
• Death may be extremely rapid. It is of 2 types
▪ Reflex cardiac arrest due to Vagal inhibition or
vasovagal stimulation
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 ▪ Laryngeal spasm and airway closure causing lethal
hypoxia
• In these cases the autopsy findings and test for
drowning are negative and lung field are dry

(b)Immersion syndrome
• Hydrocution.submersion inhibition or cold water
drowning
• It refers to a syncope resulting from cardiac
disrrhythemia on sudden contact with water,ie,at least
5oc lower than the body temp.
• The syndrome occurs as a result of
▪ cold water stimulating the nerve endings in the
surface of body
▪ water striking the epigastrium
▪ cold water entering the ear drum ,nasal
passage,pharynx and larynx
▪ falling or diving into water with feet first
• The syndrome particularly affect the middle aged or
elderly men who were drunkard underlying cardiac
disease should increase risk of sudden collapse.
• The findings of typical drowning are absent,and
diagnosis of hydrocution is difficult because of
aspiration of water into lungs does not occur.

(c)Near drowning[Post immersion syndrome/Secondary

drowning]
• It refers to survival beyond 24hrs after a submersion
episode
• Death is caused by complication
• It refer to a victim who initially respond well to
resuscitation but then suffers respiratory
decompensation

(d)Shallow water drowning[Submersion of unconscious]

Alcoholics, drunkard,epileptics ,infants and unconscious
person may die due to drowning in shallow water like pit or
drain
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 TREATMENT

Artificial respiration and closed cardiac compression should

be started immediately
• Fresh water drowning – External defibrillator applied to
the chest
• Sea water drowning – Administration of O2 and
correction of Haemo concentration
Closed chest cardiac massage:The patient is made lie on
the back. The operator places his hand one over the other
above the patient sternum. Forcible rhythmic compression
are made 60 to 80 per min to empty the blood from
ventricles

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 POSTMORTEM FINDINGS

• The diagnosis of drowning is one of the exclusion

• Any dead body whatever the cause of death will
develop signs of immersion if left for sufficient time in
water
• Moreover some of he signs are not appreciable in case
of putrification
• When freshly removed from water the body and clothe
will be wet. There must be sand and sand particles on
hand ,hair and clothes

External findings
• Face is pale ,becomes bloated and discolored cyanosis
is present.
• Eyes are found half open or closed,pupils are dilated.
Subconjuctival hemorrhage found in lower eyelids
• tongue may be swollen & protruded
• Postmortem staining:Light pink in color,present over
face,neck,front of upper part of chest,upper and lower
limbs,as the body usually floats with body down,face
down,buttocks up,legs and arms hanging down in front
of the body. With the onset of putrefaction skin of head
and neck become dark brown in color.

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• Froth:presence of white copious shaving lather like
froth in the mouth and nostril which get absent when
wiped off and reappears if pressure is applied to chest.
◦ Mechanism:Due to large amount of fluid inhalation
causes the tracheal and mucosal irritation which in
turn produces the tenacious mucus. Vigorous
agitation of seromucoid secretion , surfectant ,
aspirated water and air converts the medium to
froth
• Cutis anserina:[goose skin/goose
bumps/horripilation] is a state of puckered and
granular appearance of skin extremities immersed in
cold water due to contraction of erector pilorium
muscles.
• Washer man's hand:It is the wrinkled , sodden ,
bleached appearance of palm and soles due to
submersion of body

• Scrotum and penis get retracted in contact with cold

water
• Grass , gravel , mud are held firmly in clenched hands
due to cadeveric spasm is a vital sign of antemortam
drowning
• Rigor mortis appears early especially when a violent
struggle for life has taken before death

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Internal findings
• Lungs:Lungs are volmunous distented and shows
ballooning. In case of laryngeal spasm,there will be no
ballooning
◦ It feels heavy boggy and doughy. It may be
congested but are often pale Grey in color.
◦ Presence of mottled areas of red and Grey distented
alveoli,alternating with extravasation of bigger areas
called palta of hemorrhages.
◦ Cut section of lungs excude copious amount of blood
stained fluid
◦ The lungs overall picture has been described as
emphysema aquosom. When the patient is
unconscious at the time of drowning,edema
aquosom develops. When a dead body is thrown
into water even though lungs are hydro static,yet
there will be no signs of drowning lungs

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• Larynx , Trachea and bronchioles: presence of
sand , mud , classical water flora , diatoms , mucosa of
larynx , trachea and bronchioles may be red and
congested
• Heart and blood vessels:Left side of hart will be
empty and the right heart will be full with dark blood ,
unusually faid inconsistency because of admixture with
water
◦ Gettler test:Normally the chloride content of right
and left side of heart is nearly same. If difference is
more than 25mg%,it is suggestive of antemortam
drowning
▪ Fresh water drowning:The Cl- content is lower in
left heart compared to right because of dilution of
water
▪ Salt water drowning:Cl- content in left heart will be
greater because of Haemo concentration and mxig
with salt water.
▪ No change in chloride content seen in person
dying of laryingial spasm or Vagal inhibition
putrefaction patent foramen ovale or the saline
content of drowning medium approximates that of
blood
◦ Plasma magnesium:High level of Mg in the left side
of heart the right side in salt water
◦ Some researches consider high level of serum
stronium in left ventricle than in right as best
parameter for the diagnosis of seawater drowning
• Stomach and small intestine:stomach contains
water in 70% of cases , but the presence of muddy and
other fluid is valuable for indication of antemortam
drowning. Micro ruptures of gastric mucosa due to over
stretching of ingested fluid (Sehert’s sign) may be
seen. If the entire gastric mucosal content is collected
in a beaker it will form three layer
◦ foam in uppermost
◦ liquid in middle
◦ sediment in lower most(Wydlers’s sign)
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• Brain:Congested gray matter , softening and loss of
Grey white junction
• Liver , spleen and kidneys:Congested
• Middle ear:presence of water and hemorrhages on
the middle ear is a positive sign of antemortam
drowning(Uneo’s sign)
• Diatom test:Diatoms belong to class Bacillariophycea
and are microscopic unicellular algae

◦ They are chemically inert and almost indestructible

being resistant to strong acids . During
circulation,the diatoms enter in the circulation when
the person is alive
◦ Presence of diatoms in the lung substance , blood ,
brain , liver , kidney , bone marrow and femur (best
site for analysis) or humerus in the skeletal muscle
has been claimed to be suggestive proof for
antemortam drowning. Since diatoms resist
putrefaction,diatom test may have some value in
examination test of decomposed bodies
◦ The test is negative in dead bodies thrown in wet
and dry drowning . The test is limited by the
difficulty of excluding the possibility of
environmental contamination
◦ still diatoms test is considered as the gold standard
for diagnosis for typical drowning
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◦ At present combination of autopsy findings and
diatom test is good compromise in arriving at a
conclusion

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 DIAGNOSIS

• The diagnosis is basically one of the exclusion based

largely on the history and investigating reports of
case . When the findings are negative cause of death
may be given as ‘consistent with drowning’ or even to
admit that the cause of death is undetermined
• Decomposition of body: If the body remains in water
the lividity appears in the head,neck and chest . A
body taken from the water undergoes rapid
decomposition. Algae get attached to exposed portions
of drownd bodies multiply and form a thin layer over
the skin which may be seen in 3 to 4 days in summer.

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 MEDICO LEGAL ASPECTS

• Whether death is due to drowning

• Whether it was suicidal,homicidal or accidental
◦ suicidal – common in women
◦ homicidal – is uncommon except in the case of
infants
◦ accidental – tilting of boat in water
• The length of time that the body was in water
• Presence of all drowning signs
• Temperature of body falls rapidly
• Wrinkling of skin begin shortly after immersion
• Floating of body after 24hrs
• Skin of hand and feet become loose and peels like
glow at about 2 to 4 days
• Adipocere formation may take place about 5 to 15
days

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 DIRECTION TO THE INVESTIGATING OFFICER

• death occurring in shallow water should be considered

as homicide unless either proved
• Tying of limb or attaching a weight to a body may be a
suicide or homicide
• Bodies in water may be attacked by fishes and thus
inquest should be done at the earliest with the removal
of body. The following tasks must be done
▪ Examine the bottom of well or pond. Examine the
material object recovered and not the nature of
floor
▪ Look for the presence of hair, blood on the inner
lining of pond or well
▪ Request doctor to collect the viscera and body
fluid for chemical analysis. In case of female ,
request to collect vaginal swab too.
▪ Collect 1ltr of water in clean bottle and send along
with dead body to the forensic pathologist to
conduct diatom test
▪ Arrange for fingerprinting and DNA typing in case
of unknown dead bodies
▪ Request the doctor to visit the scene inordre to
correlate the autopsy finding with that of crime
scene

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 LAWS APPLIED IN DROWNING ACCIDENT CASES

Drowning and near drowning accident at pool lead to

severe physical,mental,emotional and financial strains on
victim and their families.

Negligence and liability in drowning accident

When it comes to pool product liability issue may arise due
to problems with the pools,machines,structure or
operations. Designers, manufacturers ,retailers and
installers all may be potentially held liable when a
defective pool causes injury,depending on how the defect
originated.
A 2007 federal law , the VIRGINIA GRAEMA BAKER POOL
AND SPA SAFETY ACT, requires that pool owners and
manufactures maintain certain safety standard to protect
from dangerous pool drains.pool safety gear ,such as life
jacket,rings and alarms are necessary in case of
emergency.

Premises liability and drowning

The property owner has a duty to ensure that the pool
doesn't pose an unreasonable hazard to others. It is their
responsibility post proper signage,restrict access to the
pool, and provide adequate safety equipment

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 DROWNING SUM – UP

Process of experiencing respiratory impairment due to

submersion or immersion in a liquid

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 EPIDEMIOLOGY

• Third leading cause of unintentional death worldwide

• In 2012 , 3,72,000 people died from drowning
• China and India account of 43% of drowning death
• Africa has the highest drowning mortality rate
• males have high mortality rate than females
• children under 5 have highest rate globally

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 CONCLUSION
The word drowning was previously used to describe fatal
events only. Drowning occurs when an individual spends
too much time with their nose and mouth submerged in a
liquid to a point where being unable to breathe

steps to prevent drowning include

• Teaching children and adults to swim and recognize
unsafe water conditions.
• Never swim alone
• use of personal flotation device on boat in unfavorable
conditions

Treatment of victim include oxygenation therapy

intravenous fluid therapy , vasopressers etc.

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 REFERENCES

• The Essential of Forensic Medicine and Toxicology – Dr.

K S Narayana Reddy - 34th edition/pg:341 – 351 /ch:13
• Concise Text book of Forensic medicine and Toxicology
- R K Sharma - 2nd edition/pg:60 – 64
• Parikh’s text book of Medical jurisprudence,Forensic
medicine and toxicology – B V Subramaniyam - 7th
edition /pg:188 - 197
• Forensic medicine for Police – Umadathan/pg 153 - 158
• Review of forensic medicine and toxicology - Goutam
Biswas - 4th edition /pg:183 - 190
• Text book of vyavahara ayurveda & vidhi vydyaka – Dr.
U R Shekar namburi/pg:128 – 134/ch:6
• https://www.cdc.gov/homeandrecreationalsafety/water-
safety/waterinjuries-factsheet.html

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