Pediatric drowning: a 20-year review of autopsied cases: I. Demographic features

Drowning is a significant cause of childhood mortality in the developed world. Males and preschool-aged children are overrepresented in most series of pediatric drowning. To obtain a better understanding of age- and gender-related factors, a retrospective review of autopsy records over a 20-year period (1984-2003) for cases of drowning (exclusive of bathtub drownings) was performed. Sixty-three consecutive cases of drowning were identified in 45 males and 18 females (ratio 2.5; P = 0.0007). The ages ranged from 9 months to 17 years, and most cases occurred in the 0- to 4-year age group (57%). Boys tended to be older than girls (5 years 9 months versus 4 years 4 months; P = 0.2133). Sites of drowning were open water (48%) and pools (44%), with children drowning in open water being significantly older than those drowning in pools (6 years 6 months versus 4 years 6 months; P = 0.0462). Most boys drowned in open water (53%), whereas most girls drowned in pools (50%). Resuscitation was attempted after the drowning episode in 84% of cases, with children aged 4 years or less having significantly higher rates than older children (P = 0.0346). The present study highlights differences in the pattern of drowning according to age and sex and may aid in developing targeted educational and preventative campaigns.     

Suicidal drowning in south Florida.

Autopsy protocols at the office of the Chief Medical Examiner were reviewed with respect to suicidal drowning. Between July 1, 1994 and June 30, 1998, there were 267 drownings and 873 people committed suicide in Broward County, Florida. Of those, 25 were suicidal drownings, representing 2.86% of all suicides, and overall the 8th leading cause of suicidal death. When considering suicide in the age group of 65 years and older, (n = 239), which accounts for 19.8% of the population and 27.4%, of all suicides, drowning represents 6.7% of all suicidal deaths, and within females in this group represents the third most common form of suicidal death (13.8%). The presence of alcohol or other drugs is less usual in elderly suicide victims than younger victims. Of the 25 drowning suicides, there was a preference for swimming pools, canals, and lakes as the locations of choice. Additional drowning and suicide related criteria were evaluated including marital status, mental health, clothing worn, previous attempts or threats, suicide notes, and personal effects at the scene; with the intention of establishing a profile for drowning by suicide. Given the relative abundance of water, the suicidal drowning rate appears to be lower than what might otherwise be anticipated.     

Lifeguards: a forgotten aspect of drowning prevention

Abstract:

An alarming number of drownings occur in lifeguarded swimming areas, where one might presume swimmers are protected from injury. One reason drownings occur in lifeguarded swimming areas is because lifeguard surveillance is a highly difficult task. Observational research suggests lifeguards are usually alert, but researchers also report egregious examples of inattention. We offer three strategies that have initial empirical support to reduce risk of drowning at lifeguarded swimming areas: (a) regular training to help lifeguards recognize they are vulnerable to drowning events and to raise their confidence; (b) regular practice via simulated emergency responses, and (c) addressing staff schedules so lifeguards can devote full attention to protecting swimmer safety while on duty. ‎     

Pediatric drowning: a 20-year review of autopsied cases: III. Bathtub drownings

Bathtub drownings are a significant cause of mortality in the pediatric population. Infants and preambulatory children are disproportionately affected, and several studies have suggested that preventative campaigns have been ineffective in the prevention of such deaths. To obtain a better understanding of the factors associated with bathtub drownings, a retrospective review of autopsy records over a 20-year period (1984-2003) was performed. Eighteen consecutive cases of bathtub drownings were identified in 8 males and 10 females (ratio, 0.8; P = 0.6374). The age ranged from 6 months to 70 months (mean, 17 months; median, 11 months), and most cases occurred in infants aged 12 months or less (72%). Males tended to be older than females (mean, 23 months versus 11 months; P = 0.1889). Associated factors included inadequate adult supervision (89%), cobathing (39%), the use of infant bath seats (17%), and coexistent medical disorders predisposing the infant or child to the drowning episode (17%). The pathologic findings included a frothy exudate (28%), pleural effusion (28%), and increased lung weight (61%). All toxicologic samples submitted for analysis were negative. The present study highlights the factors associated with bathtub drownings and may aid in the prevention of such deaths in the pediatric population.     

Characteristic features of suicidal drownings: a 20-year study

A retrospective study of cases of drowning suicide was undertaken at the Forensic Science Centre in Adelaide, South Australia for the period April 1980 to March 2000. A total of 123 cases were found, with 76 males (age, 16-88 years; average, 50.5 years; standard deviation [SD], 20.1 years) and 47 females (age, 34-88 years; average, 60.6 years; SD, 13.9 years). There were 66 fresh water drownings and 57 saltwater drownings. Female victims were significantly older than male victims for both fresh water and saltwater drownings (P < .05 and P < .01, respectively). Deaths in young women were rare. No temporal trend in drowning suicides could be shown, with annual numbers varying from 0 to 12 cases (average, 6.15; median, 7). Women preferentially chose the ocean or bath to drown themselves in, whereas males chose rivers, ditches, and lakes. Swimming pools were rarely used for suicide in this population; alcohol use was not usual; and there was often a significant history of mental illness.     

Suicide by drowning: a 20-year review

Drowning as a method of suicide is known to occur, but has primarily been described in environments with readily available access to water, such as coastal regions. In this study, we describe and analyze a series of suicidal drownings occurring in a noncoastal area of Texas. Between 1977 and 1996, 52 cases of suicidal drowning were investigated at the Southwestern Institute of Forensic Sciences in Dallas, Texas. Such deaths accounted for only 0.85% of all suicides and 4% of all drowning deaths. In contrast. suicidal drownings reportedly account for 2.8 to 8.9% of all suicides in regions with easy access to water. As with other studies of suicidal drowning, the victims are usually sober white males over the age of 40 years. Our results also confirm that certain individuals who commit suicide by drowning use weights to facilitate the process. A detailed analysis of the cases is provided. as is a synopsis of several questions that may aid in determining the manner of death in suicidal drowning cases.     

Pediatric drowning: a 20-year review of autopsied cases: II. Pathologic features

The pathologic findings in autopsies of drowning victims are nonspecific and vary from case to case. However, most reported pathologic series of drowning cases exclude children and do not take into consideration the unique circumstances surrounding bathtub drownings. In addition, the effect of resuscitation on the autopsy findings has not been studied in children. A retrospective review of autopsy records of non-bathtub drownings from a 20-year period (1984-2003) was performed and 63 cases were identified in 45 males and 18 females (age range 9 months to 17 years). The incidence of frothy exudate, pleural effusion, and increased lung weight was 43%, 36%, and 80%, respectively. The incidence of frothy exudate and the combination of all 3 factors was significantly higher in cases with no resuscitation compared with those cases with attempted resuscitation with or without delayed death. As the interval between the drowning episode and autopsy increased, the incidence of frothy exudate decreased significantly. There was no relationship between these findings and the age and sex of the decedent. Other clinical conditions or occult pathologic findings that may have contributed to death were found in 8 cases (13%). The findings highlight the need for thorough clinicopathologic correlation in cases of drowning to accurately interpret the pathologic findings.     

Serum biochemical markers in drowning: diagnostic efficacy of Strontium and other trace elements

The aim of our study was to analyse several serum biochemical markers in order to evaluate the discriminant capacity of trace elements individually and jointly in drowning (seawater drowning and freshwater drowning) and their correlation with age, sex, postmortem interval, time in water and concentrations of the trace elements in the drowning medium. Sixty-seven cases of drowning (53 seawater drownings (SWD); 14 freshwater drownings (FWD) and 73 control cases (other asphyxias, n=44, and other causes of death, n=29) were selected according to the scene, cause and circumstances of death, together with autopsy findings. Serum strontium (Sr), magnesium (Mg), sodium (Na), chloride (Cl), calcium (Ca), iron (Fe), urea, creatinine (Cr) and cardiac Troponine T (cTn-T) were measured in the left ventricle (Lv), right ventricle (Rv) and peripheral blood. Lv-Rv differences for each marker and Sr, Mg, Na, Cl, Ca and Fe concentrations in the drowning medium were determinated. Mean concentrations of Sr, Cl and Mg in both ventricles and peripheral serum and Lv-Rv differences and Ca Lv and Na Rv were significantly higher in cases of drowning than for other causes of death. In SWD, Sr, Mg, Ca, Na and Cl were significantly higher in Lv than in Rv as a result of aspirating water. In contrast, haemodilution is evident from the significantly higher levels of Fe and urea in Rv than in Lv in cases of SWD, and from the higher Mg and Cr levels in Rv in FWD. In the case of SWD, serum levels of Sr are confirmed as the best parameter for diagnosis, although other trace elements may also be useful, such as the serum concentrations of Mg and Cl. In the case of FWD, the joint determination of Sr and other biochemical markers, especially Fe, may increase correct diagnosis.     

Factors affecting strontium absorption in drownings

This study examines the effects of age, gender, a cold water medium versus warm water medium, and salinity on strontium levels determined in left ventricular blood in drownings. Significant differences in the amount of strontium absorbed into the bloodstream (p<0.001) were detected between individuals who drowned in fresh water versus those drowning in seawater, and between those drowning in cold water versus warm water (p=0.030). However, no significant differences were noted in the strontium concentrations of left ventricular blood according to gender or age.     

Aquatic fatalities--a systematic retrospective analysis

In a retrospective analysis of the autopsy material (n = 5,767) of the Institute of Legal Medicine of the Hanover Medical School covering the period of 1998-2007, all aquatic fatalities were evaluated, categorized and systematically compared under epidemiological and forensic criteria. The total of 156 cases of death by drowning (2.7 % of all autopsies) included 38 bathtub drownings and 28 deaths in the water for which no pathological anatomical cause of death could be reliably demonstrated. A control group (n = 221) was investigated for the presence of aqueous liquid in the sphenoid sinuses and compared with the findings of the drowning cases without signs of putrefaction. About 16 % of the control cases had fluid in the sphenoid sinuses compared with 57.6 % in the drowning group. Most of the drowning victims were men (60.9 %), whereas in the group of bathtub drownings the majority were women. More than half of the drowning cases (n = 89) could be classified as accidents. The individual groups showed a different incidence of findings associated with drowning.     

Comparison between lung weight and blood strontium in bodies found in seawater

This paper examines the use of lung weight increase as an indicator of seawater drowning compared to the amount of Sr absorbed by the blood. The study population was limited to male victims older than 20 years. Significant differences between cases of drowning and "non-drowning" were detected in terms of the lung-heart weight ratio (L/H) (p<0.001) or lung-body weight ratio (L/B) (p=0.005). However, using lung weight (L), L/H or L/B to distinguish between seawater drownings and saltwater non-drownings some overlap was produced. The factor rendering least overlap was L/B, which also appeared to be non-dependent on the victim's age. Our findings suggest that a value of L/B higher than 19.5 g/kg could be a useful indicator of death by drowning, but that when a lower value is found, additional drowning diagnoses would be needed to establish the manner of death.     

Temporal Trends in Rainwater Tank Suicides in Rijeka,Croatia—A 30‐year Study

Although drowning in rainwater tanks is a generally rare phenomenon, this method for suicide has been observed in parts of Croatia. Review of autopsy records at the University of Rijeka, Croatia, was undertaken from 1987 to 2016 to examine this phenomenon. Of 469 drowning deaths, there were 35 suicides in rainwater tanks (7.5%). Overall drowning deaths showed no temporal trends. In contrast, suicidal drownings in rain water tanks showed a marked decline over the years, with 15 cases in 1987–1991, seven in 1992–1996, six in 1997–2001, six in 2002–2006, one in 2007–2011, and none in 2012–2016. Thus, suicidal drowning cases as a percentage of overall drownings dropped from 18% to zero (p<0.001). This study reports a very unusual method of suicide that may have occurred because of the ready availability of large water reservoirs in homes. The recent fall in numbers may relate to less reliance on domestic reservoirs of water.     

Evaluation of postmortem serum calcium and magnesium levels in relation to the causes of death in forensic autopsy

There appears to be very poor investigation of postmortem serum calcium (Ca) and magnesium (Mg) for diagnostic evidence to determine the cause of death. The aim of the present study was a comprehensive analysis of the serum levels in relation to the causes of death in routine casework. Autopsy cases (total, n=360; 5-48 h postmortem), including blunt injury (n=76), sharp injury (n=29), asphyxiation (n=42), drownings (n=28: freshwater, n=11; saltwater, n=17), fire fatalities (n=79), methamphetamine (MA) poisoning (n=8), delayed death from traumas (n=37), and acute myocardial infarction/ischemia (AMI, n=61), were examined. In total cases, there was no significant postmortem time-dependent rise in serum Ca and Mg. Both Ca and Mg levels in the heart and peripheral blood were significantly higher in saltwater drowning compared with those of the other groups. In addition, a significant elevation in the Ca level was observed in freshwater drowning and fire fatalities, and in the Mg level in fatal MA intoxication and asphyxiation. Topographic analyses suggested a rise in serum Ca and Mg due to aspirated saltwater in drowning, that in serum Ca in freshwater drowning and fire fatalities of peripheral skeletal muscle origin and that in serum Mg in MA fatality and asphyxiation of myocardial and/or peripheral origin. These markers may be useful especially for diagnosis and differentiation of salt- and freshwater drownings and may be also helpful to determine the causes of death involving skeletal muscle damage, including burns and MA intoxication.     

Putrefaction: An Additional Complicating Factor in the Assessment of Freshwater Drownings in Rivers

Background hypothesis: That bodies immersed in freshwater (rivers) may show greater changes of decomposition than bodies immersed in saltwater (sea). Fifty de‐identified river drownings and 50 sea drownings were randomly selected from autopsy files at Forensic Science SA, Adelaide, Australia and assessed for decomposition. Results: The river cases consisted of 43 males and seven females (M:F 6:1); age range of 2–92 years (mean 46.8 years); decomposition—16/50 (32%); postmortem interval 1–14 days, average 3.8. The sea cases consisted of 36 males and 14 females (M:F 2.6:1); age range of 9–81 years (mean 50.7 years); decomposition—2/50 (4%) (p < 0.001%); postmortem interval 1–6 days, average 2.8. As decomposition reduces information obtained at autopsy, postmortem examination of deaths in rivers may be less informative than deaths that have occurred in the sea. The reasons for less decomposition in the sea include cooler temperatures, exposure to salt and shorter postmortem intervals.     

Blood strontium concentration related to the length of the agonal period in seawater drowning cases

The levels of ventricular blood strontium (Sr) from 70 seawater drowning victims were compared with their diagnosis of drowning based mainly on certain criteria selected from their autopsy report. From this comparison, intervals of either the difference of Sr concentration between the left and the right ventricle blood (LVSr-RVSr) or the Sr concentration in the left ventricle blood (LVSr), appear to be related to different time-lapses of the agonal period of drowning. In the aim to diagnose drownings, intervals of both LVSr-RVSr and LVSr were proposed to characterize three different agonal periods in seawater drowning cases: instantaneous death (ID), fast vital-submersion drowning (FVSD) and common vital-submersion drowning (CVSD).     

Vitreous humor sodium levels in immersion deaths

To determine whether vitreous humor sodium levels might be of use in evaluating deaths associated with immersion, samples of vitreous humor were prospectively evaluated at autopsy over a 4-year period from 2006 to 2009. There were 19 cases of saltwater immersion (age range 9-76 years; mean age 44 years; M:F, 2.8:1) and 16 freshwater immersions (age range 2-81 years; mean age 27 years; M:F, 2.2:1). In the group of saltwater drownings, vitreous humor sodium levels were elevated, ranging from 145 to 184 mM (mean = 160.2 ± 9.9 mM), and in the cases of freshwater drowning, the levels were reduced, ranging from 73 to 148 mM (mean = 129.8 ± 17 mM; p < 0.0001). Alterations in electrolyte levels may have been because of hemoconcentration or dilution from electrolyte fluxes in the lungs, or from passive diffusion during immersion. This study has demonstrated that vitreous sodium level is an easily performed test that may be a useful adjunct to the investigation of possible immersion deaths.     

Diagnosing death by drowning in fresh water using blood strontium as an indicator

The interpretation of the level of strontium (Sr) in blood has been demonstrated to be useful in the diagnosis of death by drowning occurred in sea water, but its use in fresh water drownings is not so evident because of the low Sr concentration present in most of fresh water media. In this paper, we show a survey of the results obtained in the casework analysis of Sr in ventricular blood used in the diagnosis of drowning in 144 bodies found immersed in fresh water over a period of 10 years. Thirty-two percent of the immersion cases examined could be diagnosed as drownings with a reasonable degree of confidence. It is thought that this percentage of positive diagnoses could be largely improved in the case of blood samples taken a few hours after death.     

Drug prevalence in drowning deaths in Cuyahoga County, Ohio: a ten-year retrospective study

Previous studies have shown that up to 50% of adult drownings are related to the consumption of alcohol. Little information is available in the literature regarding the possible contribution of ethanol and other drugs to drownings.All records of deaths occurring in Cuyahoga County, Ohio, from 1994-2003, in which drowning was listed as the cause of death, were reviewed. Toxicology analysis was performed on cases where specimens were submitted. Review of the 187 cases showed that the majority (78%) of drowning deaths were ruled as accidents, 26 (14%) as suicide, 5 (3%) as homicide, and 11 (6%) as undetermined.Among the accidental deaths (n=141), 97 (69%) were negative for all drugs, including ethanol, and 30 cases (21%) were positive for ethanol only. Illicit drugs were detected in 4 of the cases (3%). In the suicides (n=26), 16 (62%) were negative for all drugs, including ethanol, and 7 cases (27%) were positive for ethanol only (mean blood alcohol concentration [BAC] 0.03 g/dL). Illicit drugs were detected in 3 of the cases (12%). Two of the 5 homicide cases (40%) were positive for ethanol. There were no cases in which the victim tested positive for illicit drugs.Of the 11 cases ruled as undetermined, 64% (n=7) were negative for all drugs, including ethanol. The remainder of the cases tested positive for ethanol only. There were no cases in which illicit drugs were detected. This study demonstrates that the majority of drowning deaths in Cuyahoga County, Ohio, were not drug related. Deaths in which drugs were detected were typically accidental deaths, with ethanol the most common drug detected.     

Death during immersion in water in childhood.

Drowning is a relatively common cause of accidental death in children. Autopsy records at the Adelaide Children's Hospital over a 27-year period from 1964 to 1990 were examined, and 58 cases were found where the cause of death was listed as drowning. In six cases, however, careful examination of the history and postmortem findings provided important additional information that suggested a more complex antemortem sequence of events. Specifically, four patients aged between 6 years, 10 months and 11 years were known to have had epilepsy. A further patient, an 8-year-old boy, died from a subarachnoid hemorrhage due to a bleeding cerebral arteriovenous malformation while swimming. The final patient, an 11-year-old boy who collapsed in a public swimming pool, was found at autopsy to have marked hypoplasia of the right coronary artery. In this series, six of 58 (10.3%) of the pediatric cases had additional underlying medical problems that could either have initiated the drowning episode or caused death due to alternate mechanisms. We present the clinicopathological findings in detail to demonstrate that a high index of suspicion must be maintained in all cases of pediatric drowning, not only for unnatural causes of death but also for additional natural disease processes that may have contributed significantly to the fatal episode. These findings may have particular relevance in jurisdictions where full postmortem examination is not always required by law.     

Fatal Drowning Accident and Undiagnosed Hydrocephalus

Abstract: Bodies found in water present several diagnostic challenges for the forensic examiner, such as the identification of the time and mechanism of death, the postmortem submersion time, and above all the circumstances of drowning. We report the case of a 33‐year‐old security guard found dead in Venice, in the water of the lagoon, who at autopsy presented a previously undiagnosed hydrocephalus with macrocephaly. The victim remained asymptomatic until 2 months before death and had never undergone a neurological or radiological examination. In the article, we emphasize the need to perform a thorough autopsy in all suspected drownings, discuss the etiopathogenesis of the neurological disease and hypothesize a possible relationship between the hydrocephalus and the drowning accident. Finally, we discuss the major clinical and forensic implications of macrocephaly and hydrocephalus in adults.