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Drowning,[object Object]
Aim of this 2 parts class:,[object Object],1. To give you guys attendance.,[object Object],2. Theoretical, conceptual & practical know how,[object Object],3. To able you to understand the burden, mechanism, morphological, micro features,[object Object],4. To differentiate between freshwater and saltwater drowning,[object Object],5. To differentiate between AM and PM drowning,[object Object],6. To estimate the duration & Site of incidence.,[object Object]
Drowning Vs Sinking,[object Object]
Home-work ,[object Object],Difference b/w Drowning and Immersion?,[object Object]
Specific Gravity and Density,[object Object],Specific gravity is defined as the ratio of the density of a substance to the density of water.,[object Object],Water has a specific gravity of 1.0 ,[object Object],Any object with a specific gravity less than1.0 will float in water and anything greater than 1.0 will sink,[object Object],The human body has a density slightly less than that of water and averages a specific gravity of 0.974. Therefore, we float. ,[object Object],Lean body mass has a typical density near 1.1 ,[object Object], Fat mass has a density of about 0.9. ,[object Object]
Am I a stud?,[object Object]
SEQUENCE OF EVENTS IN DROWNING,[object Object],1. SENSE OF PANIC,[object Object],Expressed by:	,[object Object],Violent struggle,[object Object],Automatic swimming movements,[object Object],Usually followed by:,[object Object],2. PERIOD OF VOLUNTARY APNOEA,[object Object],Duration: 1-2 minutes.,[object Object],Hypoxemia, hypercapnia, R & M acidosis.,[object Object]
3. ATTEMPT AT TAKING A BREATH,[object Object],WATER:,[object Object],May be freely inhaled,[object Object],Or, may cause glottic spasm due to impingement.,[object Object],In 10-15 % victims:  glottic spasm severe asphyxia water may not enter the lungs unless subcouncious.,[object Object],Dry drowning,[object Object],In 85-90 % victims: water is swallowed inducing vomiting, gasping & aspiration of water into lungs. 	When expiratory effort is made: fine froth, sometimes blood stained (due to overdistension of liquid coloumn),[object Object],Wet drowning,[object Object]
4.  Cessation of constant struggling,[object Object],5. Stage of convulsive spasms, twitching, dilation of pupils,[object Object],6. Clinical death,[object Object]
Freshwater Drowning,[object Object],The Mechanism + RespPathophysiology,[object Object]
Drowning
More liquid in the circulation,[object Object],Hemodilution, decrease in Na+, Cl & Ca conc.,[object Object],Liquid/ water goes inside RBCs,[object Object],Hemolysis,[object Object],Release of K+,[object Object],Increase in K+ conc.,[object Object]
Marked Ventilation perfusion mismatch,[object Object],Shift Acute hypervolemia,[object Object],Experimental Vs Reality,[object Object],Increase in K+ irritates myocardium,[object Object],Arrythmias (VF) occurs,[object Object]
Effect on CVS,[object Object],Increase in circulatory volume but till plateau.,[object Object],Decrease in blood density,[object Object],Dec in Na, Cl,[object Object]
Salt water Drowning,[object Object],Pulling out of water  Hemoconc. Inc. in Na, Cl and Mg,[object Object],No hemolysis, No VF,[object Object],Death within 5-12 minutes (later than freshwater),[object Object]
Hypertonic liquid,[object Object],Pulmonary edema within minutes,[object Object],Shift Hypovolemia,[object Object],Draws water out through mb,[object Object],Into pulmonary alveoli,[object Object],Damage to basement mb + Dilution & washing out of Surfactant,[object Object],compliance decreased,[object Object]
Pulmonary edema X ray,[object Object]
Effect on CVS,[object Object],CVS effects are secondary to:,[object Object],1. Changes in arterial oxygen tension,[object Object],2. Changes in acid base balance.,[object Object],Acute hypoxemia Catecholamine release Transient tachycardia and hypertension.,[object Object],Followed by bradycardia and hypotension as hypoxemia intensifies.,[object Object],Hypoxemia may directly reduce myocardial contractility,[object Object],Hypoxia + Acidosis: increase the risk for arrythmias( VT, VF, Asystole),[object Object],Note: VF as an immediate cause of death is uncommon in both forms of human drowning.,[object Object]
Effects on Brain,[object Object],Hypoxia ischemic damage to brain,[object Object],Window period of 4-6 minutes before irreversible neuronal damage.,[object Object]
Effects on other organs,[object Object],Acute renal and hepatic insufficiency,[object Object],GI injuries,[object Object],DIC,[object Object]
Complications	,[object Object]
Types of drowning,[object Object],1. Wet drowning= primary drowning,[object Object],2. Dry drowning= 10-15%, laryngospasm, thick mucous foam plug, panoramic views of past life, pleasant dreams without distress.,[object Object],3. Secondary drowning= post immersion syndrome= near drowning; Secondary drowning is death due to chemical or biological changes in the lungs after a near drowning incident; resuscitated and survives for 24 hours, +/- conscious, hypoxemia brain damage, electrolyte disturbances, pulmonary edema, hemoglobinuria, chemical pneumonitis,[object Object],4. Immersion syndrome= hydrocution= submersion inhibition; cold water n. endings +/ strike epigastrium+/ entering ear drums, nasal passages. ,[object Object],Horizontal entry (dive) pressure on abdomen,[object Object],All these  Vagal inhibition Cardiac  arrest death,[object Object]
RESPIRATORY SYSTEM,[object Object],In humans: As little as 1 to 3 ml/kg produces profound alteration in pulmonary gas exchange and decreases pulmonary compliance by 10 to 40%,[object Object]
Causes of death,[object Object],1. Asphyxia,[object Object],2. VF: disturbed Na/ K ratio (freshwater),[object Object],3. Laryngeal spasm,[object Object],4. Vagal inhibition: cold water, emotions?, unexpected immersion.,[object Object],5. Exhaustion,[object Object],6. Injuries: # skull, cervical vertebrae.,[object Object]
MACRO-MORPHOLOGICAL CHANGES,[object Object],1. FOAM/ FROTH: ,[object Object],1. Mushroom like froth from mouth, nostrils.,[object Object],2. Foam inside mouth, in upper airways.,[object Object],Drowning liquid+ edema liquid+ fine air bubbles (resistant to collapse),[object Object],Blood stained: mechanism?,[object Object],3.  External foam: most valuable finding,[object Object],D/D: 	,[object Object],1. Cardiogenic PE,[object Object],2. Epilepsy,[object Object],3. Drug intoxication,[object Object],4. Electrical shock,[object Object]
Mechanism of foam formation,[object Object]
Clothing: wet,[object Object],Skin: wet, moist, pale ?,[object Object],Mud, silt, algae on body,[object Object],PM lividity: light pink in color,[object Object],Face: +/- cyanotic,[object Object],Conjunctivae: congested,[object Object],Pupils: dilated,[object Object]
Tongue: may be protruded or swollen,[object Object],Cutis Anserina: goose flesh?,[object Object],Reaction Phenomenon?,[object Object],Weed, grass, gravel in hand: due to cadaveric spasm.,[object Object],Soddening of skin of hands, feet/ shoes. Wrinkling Bleaching of epidermis in 4-8 hrs Washerwoman’s hands and feet 24-48 hrs.,[object Object]
Long standing Washer man/woman’s feet,[object Object]
2. LUNGS:,[object Object],Emphysema Aquosum,[object Object],Imprints of ribs on pleural surface,[object Object],lung SR:  Pale, mottled, red and grey areas,[object Object],Cut Section: Oozing of foamy liquid,[object Object],Subpleuralhges (Paltauf’s spots): 5-60% of drownings,[object Object],Lung weight: if taken alone, has little diagnostic value.,[object Object],Dry lungs: with no signs of aqueous emphysema (10-15%) ,[object Object]
Comparison of forensic pathology of lungs,[object Object]
Over distension and overlapping of anterior lung margin,[object Object]
Paltauf’s spots,[object Object]
3. PLEURA: ,[object Object],PE: a relatively common finding,[object Object],Due to diffusion of liquid into thoracic cavity.,[object Object],4. TEMPORAL BONE:,[object Object],Gross hges in the petrous and mastoid region of temporal bone,[object Object],Reasons:,[object Object],1. Barotrauma,[object Object],2. Penetration,[object Object],3. Increased capillary & venous pressure,[object Object]
Drowning
5. SINUSES:,[object Object],Aqueous liquid inside sinuses.,[object Object],Sign of permanence, can occur PM too.,[object Object],6. SPLEEN:,[object Object],controversial,[object Object],Cut off value 0.2% body weight.,[object Object],Decrease in weight due to (proposed):  symp. Stimulation V/c  Contraction of the spleen capsule and trabeculae,[object Object]
7. MUSCLES:,[object Object],Hges are seen, mostly in Resp & Aux resp ms > neck & back ms > ms of shoulder girdle > upper arm ms.,[object Object],Causes: Convulsions, hypercontraction, overexertion.,[object Object],8. GI:,[object Object],Laceration of GI mucosa: vague,[object Object]
When the body starts floating?  ,[object Object]
Alterations in blood,[object Object],Gettler Test:,[object Object],Normally, Cl content R=L, 600 mg/100 ml,[object Object],F.W.D= blood gets diluted by as much as 72 % in 3 minutes blood in the left side: Cl is 50 % lower than usual.,[object Object],S.W.D= Clconc increases (due to hemoconc),[object Object],25% difference= significant,[object Object],Value of the test= doubtful,[object Object]
Diatoms,[object Object],Microscopic, unicellular algae,[object Object],Siliceous skeleton = frustule,[object Object],Resist heat and acid.,[object Object],Active circulation brings diatoms into intestine, liver, brain, bone marrow.,[object Object],Technique: HNo3 or enzymatic digestion Centrifuge deposit PC or DGI Microscopy,[object Object]
Drowning
Thank you, for your patience ,[object Object]
Drowning
Pressure,[object Object],is applied using the heel of one hand with the other,[object Object],hand on top, to depress the sternum 1 in. to 11/4 in.,[object Object],with each stroke in adults, followed by release of,[object Object],pressure, at the rate of about 60 per minute.,[object Object],The application of artfficial respiration and,[object Object],cardiac massage should be continued for at least,[object Object],15 minutes,[object Object],If spontaneous respiration,[object Object],and restoration of the circulation do not occur,[object Object],within 15 minutes, further efforts are probably,[object Object],fruitless. If there is discernible evidence of active,[object Object],circulation, artificial respiration should be continued,[object Object],until spontaneous respiration is restored. On,[object Object],the other hand, marked body cooling or evidence,[object Object],of early rigor mortis indicates the futility of continued,[object Object],efforts in this direction. The presence of,[object Object],fixed dilated pupils persisting for 15 minutes is,[object Object],suggestive of clinical death.,[object Object]
In fresh-water,[object Object],drowning, this consists of 1000 c.c. of 3% saline,,[object Object],which is repeated in three to six hours if the serum,[object Object],sodium level is below 110 mEq./l. The deficit in,[object Object],serum calcium may need to be corrected by an,[object Object],infusion of calcium gluconate.,[object Object],Transfusion with whole blood, alternating with bleeding, may be,[object Object],needed later.,[object Object]
In salt-water drowning, intravenous,[object Object],therapy is carried out with 5% dextrose-never,[object Object],saline, whole blood or plasma. Venesection may be,[object Object],needed later.,[object Object]
anesthetic machine,[object Object],using intermittent pressure and pure oxygen.,[object Object],If the cardiac,[object Object],status is unsatisfactory, injections of epinephrine,[object Object],have been employed by some workers. If ventricular,[object Object],fibrillation has occurred, the use of external,[object Object],stimuli such as a quick blow over the heart, the,[object Object],application of electrodes with one or more shocks,[object Object],using 480 volts for .25 second,,[object Object]
In victims of fresh-water drowning the urinary,[object Object],output must be carefully observed; the hemolysis,[object Object],of red cells may cause renal tubular nephrosis.,[object Object]
under circumstances,[object Object],which induce emotions such as fear or surprise,,[object Object],the swimmer may be in such a state that an,[object Object],ordinarily innocuous stimulus will cause vagal inhibition,[object Object],and immediate cardiac arrest.,[object Object]

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