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Author: Lindsey Harle, M.D. (see Reviewers page)
Revised: 16 August 2012, last major update August 2012
Copyright: (c) 2012, PathologyOutlines.com, Inc.


Drowning should be considered as a possible cause of death when:
● Body is recovered from a body of water, on the banks of a body of water, or near a fluid filled container
● Body is found with head submerged in fluid (e.g. bathtub)

Stages of drowning:
● Voluntary breath holding until the urge to breath becomes overwhelming
● Fluid aspirated into airways/swallowed into GI tract
● Fluid aspiration ceases due to anoxic cerebral injury
● Anoxic cerebral injury becomes irreversible

Freshwater versus saltwater drowning:
● Any difference in severity of fresh versus salt water drowning is unproven
● Freshwater drowning: water denatures alveolar surfactant, and rapidly passes into the bloodstream producing hemolysis
● Saltwater drowning: water dilutes alveolar surfactant; circulating plasma is drawn via osmosis into alveoli, resulting in hemoconcentration and increased blood electrolyte levels

Near drowning: when a submerged individual survives greater than 24 hours after rescue
● May show pulmonary edema, hemoglobinuria, cardiac arrhythmia, pneumonitis, fever, sepsis, and sequelae of cerebral hypoxia; rapidly developing cerebral edema is a common mechanism of death

Survival in cold water drowning:
● Several reported cases of individuals surviving after prolonged immersion in cold water
● Thought to be due to the “diving reflex”: cold water immersion leading to bradycardia and vasoconstriction to all major organs, with the exception of the brain and heart

Autopsy findings:
● Drowning is a diagnosis of exclusion, based on ruling out all other causes of death via complete autopsy and toxicology
● May see bloody froth in the airway, water in the stomach, cerebral edema, petrous or mastoid hemorrhage
● “Washerwoman” changes of the hands (shriveling of the skin) develop when submerged in water for several hours; occurs regardless of whether the person died in the water
● Postmortem lacerations/abrasions due to scraping along rough surfaces in the water or animal activity should not be confused with antemortem trauma

Unconfirmed tests for drowning

Diatom test:
● Diatoms are microscope algae present in bodies of water; theoretically should never be present in a human unless they inhaled water
● Look for diatoms in bone marrow
● Validity questionable because diatoms are present in soil and atmosphere, and samples are easily contaminated
● Absence of diatoms does not rule out drowning:

Paired cardiac electrolytes:
● In saltwater drowning, Na and Cl concentrations in right and left heart blood should be widely different
● Invalid if individual survived for a period of time or had significant CPR

Sphenoid sinus fluid:
● Significant fluid in sphenoid sinuses (several milliliters) is suggestive of water aspiration; not a validated test

End of Forensics > Drowning

This information is intended for physicians and related personnel, who understand that medical information is often imperfect, and must be interpreted in the context of a patient's clinical data using reasonable medical judgment. This website should not be used as a substitute for the advice of a licensed physician.

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