Drowning Asphyxiation

[Sullivan Maurer]

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Materials and methods: Cases (n = 14) were corpses with cause of death determined as drowning by concordant autopsy findings and physical and circumstantial evidence. Controls (n = 11) were corpses in which the cause of death was defined as asphyxiation by any other manner than submersion in a liquid. Images were evaluated for the presence of fluid in paranasal sinuses, mastoid air cells and lower airways, frothy foam in the upper airways, ground-glass opacity of the lung parenchyma, the height of the right hemi-diaphragm, the interpulmonary distance at the level of the aortic valve, the mean density of intracardiac blood, and gastric and esophageal contents. Descriptive statistics, Fisher's exact test, and Student's t test were used when appropriate.

Conclusion: Our results indicate that it is not possible to reliably distinguish drowning from non-drowning asphyxiation on CT, because many findings in drowning were also present in non-drowning asphyxiation. CT indicators for drowning as the cause of death should therefore be defined with great caution, keeping in mind that they are not specific to only a single cause of death.

Cynthia Taylor Chavoustie is an experienced physician assistant specializing in urgent care, family medicine, and gastroenterology. She has been a licensed physician assistant since 2001 and has clinical experience with all ages and in many environments.

Dr. Jill Seladi-Schulman is currently a freelance medical writer and was previously a project setup manager for clinical trials. She specializes in microbiology and infectious disease, having written her dissertation on influenza virus morphology. Dr. Seladi-Schulman has publications in peer-reviewed journals. She also has had her work featured on the cover of the Journal of Virology.

Chemical asphyxia may also occur if you use inhalants. These substances are often found in common household products, and they have chemical fumes that cause psychoactive effects when inhaled. In high amounts, these fumes can lead to asphyxiation.

Drowning is a type of suffocation induced by the submersion of the mouth and nose in a liquid. Submersion injury refers to both drowning and near-miss incident. Most instances of fatal drowning occur alone or in situations where others present are either unaware of the victim's situation or unable to offer assistance. After successful resuscitation, drowning victims may experience breathing problems, vomiting, confusion, or unconsciousness. Occasionally, victims may not begin experiencing these symptoms until several hours after they are rescued. An incident of drowning can also cause further complications for victims due to low body temperature, aspiration of vomit, or acute respiratory distress syndrome (respiratory failure from lung inflammation).

Drowning is more likely to happen when spending extended periods of time near large bodies of water.[4][6] Risk factors for drowning include alcohol use, drug use, epilepsy, minimal swim training or a complete lack of training, and, in the case of children, a lack of supervision.[6] Common drowning locations include natural and man-made bodies of water, bathtubs, and swimming pools.[3][7]

Drowning occurs when a person spends too much time with their nose and mouth submerged in a liquid to the point of being unable to breathe. If this is not followed by an exit to the surface, low oxygen levels and excess carbon dioxide in the blood trigger a neurological state of breathing emergency, which results in increased physical distress and occasional contractions of the vocal folds.[9] Significant amounts of water usually only enter the lungs later in the process.[4]

While the word "drowning" is commonly associated with fatal results, drowning may be classified into three different types: drowning that results in death, drowning that results in long-lasting health problems, and drowning that results in no health complications.[10] Sometimes the term "near-drowning" is used in the latter cases. Among children who survive, health problems occur in about 7.5% of cases.[7]

Steps to prevent drowning include teaching children and adults to swim and to recognise unsafe water conditions, never swimming alone, use of personal flotation devices on boats and when swimming in unfavourable conditions, limiting or removing access to water (such as with fencing of swimming pools), and exercising appropriate supervision.[6][5] Treatment of victims who are not breathing should begin with opening the airway and providing five breaths of mouth-to-mouth resuscitation.[7] Cardiopulmonary resuscitation (CPR) is recommended for a person whose heart has stopped beating and has been underwater for less than an hour.[7]

A major contributor to drowning is the inability to swim. Other contributing factors include the state of the water itself, distance from a solid footing, physical impairment, or prior loss of consciousness. Anxiety brought on by fear of drowning or water itself can lead to exhaustion, thus increasing the chances of drowning.

Approximately 90% of drownings take place in freshwater (rivers, lakes, and a relatively small number of swimming pools); the remaining 10% take place in seawater.[11] Drownings in other fluids are rare and often related to industrial accidents.[12] In New Zealand's early colonial history, so many settlers died while trying to cross the rivers that drowning was called "the New Zealand death".[13]

Death can occur due to complications following an initial drowning. Inhaled fluid can act as an irritant inside the lungs. Even small quantities can cause the extrusion of liquid into the lungs (pulmonary edema) over the following hours; this reduces the ability to exchange the air and can lead to a person "drowning in their own body fluid". Vomit and certain poisonous vapors or gases (as in chemical warfare) can have a similar effect. The reaction can take place up to 72 hours after the initial incident and may lead to a serious injury or death.[15]

A conscious person will hold their breath (see Apnea) and will try to access air, often resulting in panic, including rapid body movement. This uses up more oxygen in the bloodstream and reduces the time until unconsciousness. The person can voluntarily hold their breath for some time, but the breathing reflex will increase until the person tries to breathe, even when submerged.[28]

The breathing reflex in the human body is weakly related to the amount of oxygen in the blood but strongly related to the amount of carbon dioxide (see Hypercapnia). During an apnea, the oxygen in the body is used by the cells and excreted as carbon dioxide. Thus, the level of oxygen in the blood decreases, and the level of carbon dioxide increases. Increasing carbon dioxide levels lead to a stronger and stronger breathing reflex, up to the breath-hold breakpoint, at which the person can no longer voluntarily hold their breath. This typically occurs at an arterial partial pressure of carbon dioxide of 55 mm Hg but may differ significantly between people.

When submerged into cold water, breath-holding time is significantly shorter than that in air due to the cold shock response.[29] The breath-hold breakpoint can be suppressed or delayed, either intentionally or unintentionally. Hyperventilation before any dive, deep or shallow, flushes out carbon dioxide in the blood resulting in a dive commencing with an abnormally low carbon dioxide level: a potentially dangerous condition known as hypocapnia. The level of carbon dioxide in the blood after hyperventilation may then be insufficient to trigger the breathing reflex later in the dive.

Following this, a blackout may occur before the diver feels an urgent need to breathe. This can occur at any depth and is common in distance breath-hold divers in swimming pools. Both deep and distance free divers often use hyperventilation to flush out carbon dioxide from the lungs to suppress the breathing reflex for longer. It is important not to mistake this for an attempt to increase the body's oxygen store. The body at rest is fully oxygenated by normal breathing and cannot take on any more. Breath-holding in water should always be supervised by a second person, as by hyperventilating, one increases the risk of shallow water blackout because insufficient carbon dioxide levels in the blood fail to trigger the breathing reflex.[30]

The hypoxemia and acidosis caused by asphyxia in drowning affect various organs. There can be central nervous system damage, cardiac arrhythmia, pulmonary injury, reperfusion injury, and multiple-organ secondary injury with prolonged tissue hypoxia.[32]

A lack of oxygen or chemical changes in the lungs may cause the heart to stop beating. This cardiac arrest stops the flow of blood and thus stops the transport of oxygen to the brain. Cardiac arrest used to be the traditional point of death, but at this point, there is still a chance of recovery. The brain cannot survive long without oxygen, and the continued lack of oxygen in the blood, combined with the cardiac arrest, will lead to the deterioration of brain cells, causing first brain damage and eventually brain death after six minutes from which recovery is generally considered impossible. Hypothermia of the central nervous system may prolong this. In cold temperatures below 6 C, the brain may be cooled sufficiently to allow for a survival time of more than an hour.[33][34]

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