Accidental bathtub drowning not so uncommon

HYDERABAD:

• Drowning is the third most common cause of accidental death

• Risk factors for drowning include use of alcohol and illicit drugs, hypothermia, seizures, and developmental disorders.

• Drowning ultimately produces tissue hypoxia, which affects virtually all tissues and organs within the body.

• First aid: If the patient does not respond to the delivery of two rescue breaths that make the chest rise, the rescuer should immediately begin performing cardiopulmonary resuscitation (CPR).

• The Heimlich maneuver or other postural drainage techniques to remove water from the lungs are of no proven value, and rescue breathing should not be delayed in order to perform these maneuvers.

• Complete recovery of patients with hypothermia and cardiac arrest has been well documented despite prolonged resuscitation (sometimes up to several hours).

Causes of drowning in tub

• The bathtub is the most common site of seizure-induced drowning, and patients with epilepsy should be told to take showers instead of baths.

• Heart attack leading to syncope and subsequent falling in the tub. A gasping patient with ventricular arrhythmia will end up with drowning. In post-mortem the coronary arteries will show plaque and its rupture

• Undetected primary cardiac arrhythmia is a common cause of drowning. As an example, cold water immersion and exercise can cause fatal arrhythmias in patients with the congenital long QT syndrome type 1.

• Mutations in the cardiac ryanodine receptor (RyR)-2 gene, which is associated with familial polymorphic VT in the absence of structural heart disease or QT prolongation, have been identified in some individuals with unexplained drowning.

• Duration of submersion >5 minutes (most critical factor)

• Use of alcohol and illicit drugs (more than 50% of adult drowning deaths are alcohol-related).

• Hypothermia, which can lead to rapid exhaustion or cardiac arrhythmias.

• Concomitant trauma, paralysis or heart attack

• Sudden death in a hot bathtub occurs frequently in Japan, particularly among elderly people.

• According to Am J Forensic Med Pathol research in 2013, 268 victims were found unconscious or dead during tub bathing. After postmortem examination, the manner of death was judged as natural cause in 191 (71.2%) and accidental drowning in 63 (23.5%) cases. Mean age (SD) was 72.1 (15.2) years with no significant difference between males and females. A seasonal difference was evident: the winter displayed the highest frequency. Drowning water inhalation, which was confirmed in 72% of victims, was absent in the others. The most common observations on postmortem examination were cardiac ischemic changes and cardiomegaly. Water inhalation signs were evident in a significantly fewer victims exhibiting these factors. In contrast, inhalational findings were observed more frequently in victims with other backgrounds such as alcohol intake, mobility disturbance, and history of epilepsy. Annual mortality in Japan from accidental drowning in persons over 75 years is 33 deaths per 100,000 population. This number may be underestimated as pathologists tend to regard lack of water inhalation as indicating a natural cause of death.

What happens after antemortem drowning

• Fine, white, leathery, copious froth or foam tinged with blood, seen at the mouth and nostrils (Froth is of lasting nature and large in quantity),  Cadaveric spasm in hands

• Finding of diatoms by microscopic examination of tissues from brain, liver and bone marrow of long bones: such as femur, tibia, and humerus or sternum. of water in stomach and intestines

• The voluminous water logged lungs

• The presence of fine froth in lungs and air passages

      (The doctor is Padma Shri awardee, President HCFI and past national President of Indian Medical
       Association)