Near-drowning and clinical laboratory changes
Introduction
In 1921, Gettler [1] reported a decrease of the serum chloride concentration of blood from the left heart in human drowning victims in fresh water and an increase of the chloride level after drowning in sea water. As a consequence a discussion arouse on the diagnostic value and the fatal sequelae of these phenomena. Meanwhile numerous attempts have been made to confirm Gettler’s findings by comparative determination of the electrolyte concentrations as well as of hemoglobin- and/or protein-values in blood from the right and left side of the heart of drowned human victims, but the results largely have been disappointing [2], [3], [4].
On the other hand, animal experiments gave reproducable evidence on a different – but distinct – biochemical influence of water on the drowning process, especially marked by a fresh water induced red cell lysis, hyperkalemia and cardial fibrillation [5], [6], [7], [8], [9]. Those findings are based on an experimental insufflation of 10–50 ml/kg water in lungs of anesthetized animals which finally leads to a ventricular fibrillation secondary to an increase of serum potassium as a consequence of intravascular erythrocytic lysis [10]. This process was caused by the water flux from pulmonary alveoli into the intravasal compartment.
In humans, however, as little as 1–4 ml/kg water will be aspirated during drowning (about 300 ml/person – see [3], [11]). This event may primary produce alterations in the pulmonary gas exchange and a decrease of pulmonary compliance by 10–40% [12], [13], [14], [15]. Obviously humans rarely aspirate sufficient water quantities to provoke significant electrolyte disturbances [16]. In different studies of electrolyte measurements after survived drowning most of the victims needed no initial electrolyte corrections [17], [18]. Ventricular fibrillation in drowned humans obviously is related to acidosis and hypoxia and not to hemolysis and hyperkalemia, as the aspiration of water initially causes breath holding and laryngospams finally leading to hypoxic injury of the brain. In humans the aspiration of fresh or sea water may produce surfactant destruction, alveolitis, a non-cardiogenic pulmonary edema and a blockage of alveolar-capillary gas exchange. The increased pulmonary shunt may lead to a profound and partly fatal hypoxia [3], [18], [19], [20], [21], [22].
Despite of these general accepted hypotheses, the drowning process in humans is still under discussion. In a recent published leading German textbook on legal medicine [23], the chapter,, Drowning“ sums up the electrolyte disturbances of animal experiments in connection with an explanation of the human drowning process [24]. Therefore an additional proof of the pathophysiologic background seems to be necessary which is based on clinical laboratory findings in victims of near-drowning in a retrospective study answering the question (see also [24]): Do these data give any evidence on an electrolyte imbalance which eventually will influence the dying process by drowning?
Section snippets
Cases
The evaluation was based on 31 victims of near-drowning. The clinical data, the police protocols and the autoptic findings were considered. 21 victims died with delay and 10 cases survived. Male victims predominated (m:f = 20:11). The mean age was 15.5 years as most of the victims have been younger than 16 years. All cases needed cardiopulmonary resuscitation.
The duration time of suspension was unknown in all cases as well as the temperature of the water. The type of water in most cases was fresh
Results
The results are presented in Table 1. As no significant nor systemic differences could be established between immersion by fresh or brackish water we summed up the results of both groups and documented only the different results of surviving and fatal cases.
Discussion
Drowning is a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium [25], [26]. In the beginning of the drowning process the victim voluntary hold his breath followed by an unvoluntary period of laryngospasm [27]. The victim then becomes hyperbaric, hypoxemic, and acidotic which results in a abating of the laryngospasm and active breathing [28]. If the victim is not ventilated soon enough circulatory arrest will ensue as a consequence of multiple organ
References (48)
- et al.
The reliability of cardiac haemodilution as a diagnostic test of drowning
Forensic Sci Int
(1992) - et al.
Near-drowning: fresh, salt and cold water immersion
Clin Sport Med
(1986) Near-drowning and drowning classification: a proposal to stratify mortality based on the analysis of 1,831 cases
Chest
(1997)- et al.
Drowning. Rescue, resuscitation and reanimation
Ped Clin North America
(2001) - et al.
Recommended guidelines for uniform reporting of data from drowning: the “Utstein style”
Resuscitation
(2003) - et al.
Systematic review of definitions for drowning incidents
Resuscitation
(2005) - et al.
Possible postmortem serum markers for differentiation between fresh-, saltwater drowning and acute cardiac death: a preliminary investigation
Legal Med
(2003) - et al.
The natural biochemical changes during ventricularfibrillation with cardiopulmonary resuscitation and the onset of postfibrillation pulseless electrical activity
Am J Emerg Med
(2006) - et al.
The hemodynamic and cardiovascular effects of near-drowning in hypotonic, isotonic, or hypertonic solutions
Ann Emerg Med
(1989) A method for the determination of death by drowning
JAMA
(1921)
Blood changes in man following death due to drowning
AMA Arch Pathol
The pathophysiology and treatment of drowning and near-drowning Springfield/Ill
Fresh water and sea water drowning. A study of the terminal cardiac and biochemical events
Texas Rep Biol Med
The cardiorespiratory and biochemical events during rapid anoxic death. VI. Fresh water and sea water drowning
Texas Rep Biol Med
Zur Aganochemie des Ertrinkens
Beitr Gerichtl Med
Hämodynamische Dysregulation beim Ertrinken in verschieden-osmolaren Flüssigkeiten
Beitr Gerichtl Med
Physiologic effects of near drowning with chlorinated fresh water, destilled water and isotonic saline
Anaesthesiology
Wasserunfälle
Drowning by total immersion, effects on pulmonary surfactants of destilled water, isotonic saline and sea water
Am J Dis Child
Drowning and the diving reflex in man
Med J Aust
Effects of tonicities of saline solutions on pulmonary injury in drowning
Crit Care Med
Pulmonary edema, pneumonia and mortality in submersion victims. A retrospective study in 125 patients
Intens Care Med
Drowning
Cited by (20)
European Resuscitation Council Guidelines for Resuscitation 2015. Section 4. Cardiac arrest in special circumstances
2015, ResuscitationCitation Excerpt :A retrospective study of 160 children who drowned in the Netherlands found that outcomes were extremely poor if ALS took longer than 30 min to achieve ROSC even if hypothermia was present.560 Small differences in electrolyte disturbance are rarely of any clinical relevance and do not usually require treatment.575,576 The predominant pathophysiological process in the lungs is driven by surfactant wash-out and dysfunction, alveolar collapse, atelectasis, and intrapulmonary shunting.
Feasibility of pulse oximetry in the initial prehospital management of victims of drowning: A preliminary study
2011, ResuscitationCitation Excerpt :Drowning remains a common cause of accidental death.1–3 Many victims of drowning suffer from hypoxia, which should be treated with oxygen as soon as possible.4–6 Delivery of oxygen by lifeguards is therefore becoming a popular on beaches, in swimming pools and on rescue boats.7,8
Medical examiner and medical toxicologist agreement on cause of death
2011, Forensic Science InternationalDetection of diatom in formalin-fixed tissue by proteinase K digestion
2009, Forensic Science InternationalCitation Excerpt :The diagnosis of drowning is one of the most difficult among all the diagnoses performed in the legal medicine [1]. A great number of indicators have been suggested to be valuable for this diagnosis [1–8]. With increasing postmortem time, most of the above mentioned indicators are rendered unidentifiable.
Drowning
2012, New England Journal of MedicineCitation Excerpt :If the person remains unresponsive without an obvious cause, a toxicologic investigation and computed tomography of the head and neck should be considered.41 Measurements of electrolytes, blood urea nitrogen, creatinine, and hematocrit are rarely helpful; abnormalities are unusual,20 and correction of electrolyte imbalance is rarely needed.42 Persons who have good arterial oxygenation without adjuvant therapy and who have no other associated morbidity can be safely discharged.