DROWNING

FORENSIC ASPECTS
by Francisco Alexandre Antunes Santos
 Index
DEATH BY DROWNING I
1 Circumstances of body in water; Death by drowning data; Drowning risk factors; Definition
of drowning.

DEATH BY DROWNING II
2 Difference between drowning and immersion; Physiopathology and the distinct phases of
drowning.

TYPICAL VS ATYPICAL DROWNING

3 Vicious cycle of drowning.

DROWNING AND ITS MEDICO-LEGAL ASPECTS

4 Post-mortem findings: internal and external; Diatoms.
DEATH BY DROWNING I

Circumstances of body in water

• Died from natural disease before falling into the water;

• Died from natural disease while already in the water;

• Died from injury before being thrown into the water;

• Died from injury while already in the water;

• Died from effects of immersion other than drowning;

• Died from drowning.

 DEATH BY DROWNING I

Drowning data

90%

3rd 372K 42/d

Drowning is the 3rd leading
cause of unintentional injury
death worldwide, accounting
for 7% of all injury-related
deaths.
In 2019, an estimated 372000
people died from drowning,
making drowning a major
public health problem world-
wide.
Each day, 42 people die Low- and middle-income
from drowning on aver- countries account for over
age around the world. 90% of unintentional drown-
ing deaths.

Source: WHO 2019

DEATH BY DROWNING I

Risk factors Source: WHO 2019

• Age: ‘‘Males are especially at risk of drowning, with twice the overall mortality rate of fe-
males’’;
• Access to water: ‘‘Individuals with occupations such as commercial fishing or fishing
for subsistence, using small boats in low-income countries are more prone to drowning’’;
• Flood disasters: ‘‘Drowning accounts for 75% of deaths in flood disasters. Flood disas-
ters are becoming both more frequent as well as more severe and this trend is expected to
continue as part of climate change’’;
• Travelling on water: ‘‘Daily commuting and journeys made by migrants or asylum
seekers often take place on overcrowded, unsafe vessels lacking safety equipment or are op-
erated by personnel untrained in dealing with transport incidents or navigation’’;

• Other risk factors, such as:

- lower socioeconomic status;
- infants left unsupervised or alone with another child around water;
- alcohol use, near or in the water;
- medical conditions, such as epilepsy;
- tourists unfamiliar with local water risks and features;
 DEATH BY DROWNING I

Definition of death by drowning

‘‘Death by drowning is defined as a death due to submersion in a liquid
and the mechanism in acute drowning is hypoxemia and irreversible
cerebral anoxia’’

‘‘Complete submersion is not necessary. Submersion of nose and mouth is

enough’’
 DEATH BY DROWNING II

Drowning vs Immersion
• In forensic medicine, there is a constant challenge which consists of
differentiating the death by submersion from immersion of a dead body. In
fact, the external examination and the autopsy findings are in most of
the cases not specific and the laboratory investigations are controversially
appreciated by the scientific community.

• This way, there are signs of immersion that should be mentioned, that
are also present in cases of death by drowning.
 DEATH BY DROWNING II

Signs of Immersion
• Maceration of the skin – warm water;
• ‘Washer-woman’s’ skin;
• Keratin of hands and feet peels off in ‘gloves and stockings fashion;
• Nails and hair get loose;
• ‘Cutis anserina’ – cold water;
• Float with buttocks uppermost, head and limbs down;
• Decomposition:
4 – 10 days: often first in the head, neck, abdomen and thighs;
2 – 4 weeks: bloating of face and abdomen with marbling veins and peeling off epidermis on hands and feet;
1 – 2 months: gross skin shedding, muscle loss with skeletal exposure, partial liquefaction.
 DEATH BY DROWNING II

Causes of death in immersed bodies

• Myocardial infarct;
• Accidental or suicidal injuries;
• Trauma in the water;
• Sudden entry of water in the pharynx and larynx as well in the nasal passages can
produce powerful stimulation of nerve endings in the mucosa. This means the vagal
cardiac fibres are synergically stimulated by two independent reflexes: the sudden entry
of water has a stimulant effect whereas the fear or the impact of the fall has a depressant effect,
resulting in a reflex cardiac arrest. Bolus of water entering the trachea may also
cause reflex cardiac arrest;
DEATH BY DROWNING II

PHYSIO
PATHOL-
OGY
 DEATH BY DROWNING II

Phases of Drowning
The process of drowning has 3 distinct phases and leads to loss of conscience and ultimately death.

1 Breath holding 2 Involuntary inspiration 3 Loss of conscience

For a variable time,
there’s accumulation of
CO2, and stimulation of
the RC in the brain.
The water enters the alveolar spaces, de-
stroying the surfactant inducing pulmonary
edema. This non-cardiogenic pulmonary
edema will lead do metabolic acidosis and
a decrease in the lung compliance and ven-
tilation-perfusion mismatch resulting in
hypoxemia.
In state of hypoxemia, enough
oxygen does not reach the cells,
specially those who need it more,
such as nervous cells. This way,
the brain completely shuts down
and so does the rest of the body.

While the body conscience is lost, there is permanent damage being made to the brain, as well as an ongoing cardiac fail. This of
course leads to the ultimate but inevitable consequence: DEATH
TYPICAL VS ATYPICAL DROWNING
TYPICAL DROWNING
Obstruction of air passages and lungs
by inhalation of fluid. It’s known as
‘‘wet drowning’’.
Typical signs are found at the time of
autopsy, from which we can know if it
was saltwater drowning or freshwater
drowning
ATYPICAL DROWNING
Conditions in which there is very little
or no inhalation of water or fluid in the
air passages. Therefore, known as ‘‘dry
drowning’’.
There are three scenarios when atypical
drowning happens: when there’s in-
tense laryngeal spasm due to entry of
water in nasopharynx and larynx; due
to immersion syndrome; as a result of
the submersion of the unconscious; and
lastly because of the secondary/near
drowning syndrome.
TYPICAL DROWNING
SALTWATER DROWNING

• As the sea water is very hypertonic relative to the blood, the water movement goes from blood into
the alveoli and the electrolytes (sodium, chloride, magnesium) from the alveoli into the blood.

• The consequences of the sea water drowning should be hemoconcentration, hypovolemia and hyper-
natremia.

• This will of course lead to pulmonary edema, and cardiac arrest.

TYPICAL DROWNING
FRESHWATER DROWNING

• It was stated that fresh water is hypotonic and hyponatremic relative to blood inducing, after inhala-
tion, a movement of water from the alveoli into the blood and movement of sodium from the blood
into the alveoli. These changes induce haemodilution, hypervolemia, hyponatremia, hyperkalemia
and haemolysis.

• In a hyperkalemia scenario, the excess of potassium may be fatal. The excess of potassium has its
origin in the marked hypervolemia, which leads to red blood cells swelling and destruction –
haemolysis.

• The hyperkalemia will decrease the nerve flow, therefore hamper muscular contraction and the heart
beats will decrease, as well as the blood circulation.

• Within 4-5 minutes, there will be ventricular fibrillation due to anoxia and potassium excess.
VICIOUS CYCLE OF DROWNING

Deep inspiration

Gasping for air Water enters RP

Air driven out of

Cough reflex
lungs
DROWNING MEDICO-LEGAL ASPECTS

POSTMORTEM EXTERNAL FINDINGS

• Fine froth at the nose: consists of proteinaceous exudates and surfactant mixed with the water
of the drowning environment. It’s usually white, but may be pink or red-tinged, due to slight
admixture with blood from intrapulmonary bleeding.

• Presence of weeds, mud, etc.

DROWNING MEDICO-LEGAL ASPECTS

POSTMORTEM EXTERNAL FINDINGS

• Cutis anserina (goose skin): due to spasm of the erector pilae muscles and to exposure to
cold water at the time of death. Skin appears granular and puckered, with hair standing on the end. It
mainly affects the extremities of the body.

• The skin of the extremities may be also wrinkled, bleached or swollen.

• Thickened epidermis.

• Changes due to immersion.

DROWNING MEDICO-LEGAL ASPECTS

POSTMORTEM INTERNAL FINDINGS

Lungs and respiratory tract:

• Airways filled with froth, sand, seaweeds, etc. found in water.

• Lungs are voluminous, edematous, doughy to feel with rib markings.
• Paltauf’ hemorrhages.
• Emphysema Aquosum.
• Weight up to three times the original.

Other findings on other tracts:

• Hemorrhages in the middle ear and mastoid air cells

• The stomach may contain watery fluids and sand or
Seaweeds.
DROWNING MEDICO-LEGAL ASPECTS

DIATOMS
• Microscopic unicellular algae found in water
• Silicaceous cell wall which resists to acid digestion, heat and putrefaction.
• Size: 10-80 microns
• Only a live body can transport diatoms from lungs to the brain or bone marrow.

 Isolation of diatoms: 1acid digestion of tissue normally coming from bone marrow, lungs,
blood or kidney. 2centrifugation and washing. 3residue is examined under phase contrast
microscopy.
Thank you