11/130. Pulmonary interstitial fibrosis following near-drowning and exposure to short-term high oxygen concentrations. Following near-drowning in fresh water, a 19-year-old man experienced severe adult respiratory distress syndrome, necessitating ventilatory support with positive end-expiratory pressure and high oxygen concentrations. Post-extubation, his course was highlighted by persistent hypoxemia and interrupted by a lung abscess which responded promptly to antibiotics. Pulmonary function tests were consistent with severe restrictive disease and chest radiograph revealed persistent bilateral alveolar and interstitial infiltrates. An open lung biopsy on the 26th hospital day showed interstitial fibrosis. Over the ensuing two months, the chest radiograph and pulmonary function tests returned towards normal. We attribute the pulmonary fibrosis to incomplete resolution of the alveolar interstitial pathology secondary to the near-drowning and exposure to high oxygen mixtures. ( info) |
12/130. Respiratory colonization with pseudomonas putrefaciens after near-drowning in salt water. pseudomonas putrefaciens, a marine organism infrequently found in human culture material, was repeatedly isolated from the sputum of a patient with pneumonia during a three-week period following a salt-water drowning accident. Similar organisms were found in the water at the site of the accident in boston, and at ocean bathing beaches on nearby Martha's Vineyard. ( info) |
13/130. Postmortem diffusion of drugs from the bladder into femoral venous blood. We describe significantly elevated drug concentrations in the femoral venous blood due probably to postmortem diffusion from the bladder. A 16-year-old deceased male was found in a shallow ditch in winter. The estimated postmortem interval was 9 days and putrefaction was not advanced. The cardiac chambers contained fluid and coagulated blood and a small amount of buffy coat clots. Diffused hemorrhages were found in the gastric mucosa. The bladder contained approximately 600 ml of clear urine. Gas chromatographic-mass spectrometric analysis of the urine disclosed allylisopropylacetylurea (a fatty acid ureide sedative), diphenhydramine, chlorpheniramine and dihydrocodeine. The cause of death was considered to be drowning due to a drug overdose and cold exposure. The concentrations of diphenhydramine, free dihydrocodeine and total dihydrocodeine in the femoral venous blood (1.89, 3.27 and 3.30 microg/ml, respectively) were much higher than those in blood from the right cardiac chambers (0.294, 0.237 and 0.240 microg/ml, respectively). urine concentrations of diphenhydramine, free dihydrocodeine and total dihydrocodeine were 22.6, 37.3 and 43.1 microg/ml, respectively. The stomach contained negligible amounts of diphenhydramine, free dihydrocodeine and total dihydrocodeine (0.029, 0.018 and 0.024 mg, respectively); concentrations of these drugs in the femoral muscle were 0.270, 0.246 and 0.314 microg/g, respectively. These results indicate that postmortem diffusion of diphenhydramine and dihydrocodeine from the bladder resulted in the elevated concentrations of these drugs in the femoral venous blood. Not only high urinary drug concentrations but also a large volume of urine in the bladder might accelerate the postmortem diffusion. ( info) |
| angelman syndrome is characterized by mental retardation, seizures, ataxia, inappropriate laughter, lack of speech, a particular facial appearance, and generally a chromosome 15q11-q13 deletion. Recently, a fascination with water and water-related activities has been reported in individuals with the syndrome. We report on a 9.6-year-old male previously diagnosed with angelman syndrome who died unexpectedly by drowning in a shallow backyard wading pool. This case further illustrates the fascination with water by individuals with angelman syndrome and highlights that this fascination may lead to death. We wish to alert careproviders that this fascination with water and water-related activities may contribute to death and that these individuals should be closely supervised when in the presence of water. ( info) |
15/130. Drowning: another plunge. Hypoxia, pulmonary edema, acidosis, and aspiration compose the syndrome of near drowning. A review of 20 cases of near drowning indicated that the initial chest roentgenogram bears little weight in assessing the present or future clinical status. In some cases a 24 to 48 hour delay occurred before roentgenographic evidence for pulmonary edema was noted. The composition of fluid aspirated does not affect the outcome. The results of this report suggest that patients with a history of near drowning should be followed closely for at least 48 hours despite an initial normal chest roentgenogram. ( info) |
16/130. Neurodevelopmental outcome for extended cold water drowning: a longitudinal case study. There is little longitudinal data examining outcome of pediatric near-drowning. Most literature tracks status 5 years or less post insult, focusing primarily on gross neurologic status as opposed to more subtle neurocognitive deficits. The present case tracks the neuropsychological profile of a child who was submerged for 66 min, the longest time documented. Acute medical support was aggressive, and recovery was dramatic, being featured in multiple media reports. Although an article published 6 years after the near-drowning described the child as "recovering completely," the longitudinal profile indicates a pronounced pattern of broad cognitive difficulties, particularly notable for global memory impairment. Neuropsychological test results were significant despite the fact that the patient's recent MRI and MEG were within normal limits. This case demonstrates the need for long-term neuropsychological follow-up of pediatric patients with histories of neurologic injury, as gross neurological examination and MRI and MEG scans may not reveal underlying brain dysfunction. ( info) |
17/130. Did he drown or was he murdered? An unemployed, 60-year-old Singaporean gentleman died during a brief overseas trip to another South-East Asian country. He had, presumably, drowned in the bathtub of his hotel room, which he shared with his then 44-year-old companion, who was supposedly his nephew. The relevant public health and medico-legal authorities of the host country conducted an external examination of the body at the scene, whereupon they agreed with the police that his death was probably due to accidental drowning following an episode of syncope. It would appear that this verdict was based almost entirely on circumstantial and hearsay evidence. No autopsy was performed. In its place, considerable reliance was placed on the observation that abdominal compression resulted in the outflow of a small amount of water from the mouth, as being proof of drowning. A few days later, the body was cremated in the host country and the remains (ashes) were subsequently repatriated to singapore. It later transpired that, shortly before they embarked on the ill-fated trip, the deceased's 'nephew' had purchased, on the former's behalf, travel insurance policies (covering accidental injury and death) amounting to a total of S$800,000 from five different insurance companies, as well as a separate life policy for a further S$100,000, most of which had been issued within the fortnight prior to their departure. Interestingly, the beneficiary (later the plaintiff in the ensuing civil trial some three years later) of all of these policies, was the ex-wife of the deceased's 'nephew', with whom he had, in fact, continued to live although they were officially divorced several years ago. Whilst the claim against the life policy had been settled, the first five insurers declined to issue payment on grounds of suspicion that the deceased had been the victim of a homicide, planned or executed by the 'nephew', wherein the beneficiary was a conspirator of sorts. The author was approached by defence counsel (representing the various insurers), for assistance in this matter. It was felt that a proper forensic review was seriously hampered by the lack of a full autopsy which would have been indispensable in ascertaining the actual cause of death and in eliminating other possibilities, apart from drowning, such as death from natural causes, other forms of injury, poisoning, or homicide. It was also emphasized that the mere presence of ingested water is not diagnostic of drowning. Eventually, after a protracted but unsuccessful attempt at mediation (in the course of which, the plaintiff rejected the offer of a reduced, although apparently sizable quantum), the matter came before the High Court, which found in favour of the defendants. It appeared that the judge was more than convinced that the deceased was indeed the victim of a homicide of which the plaintiff was a conspirator and her ex-husband, the perpetrator, as even a cursory perusal of the written judgement would indicate. Accordingly, the court ruled that the plaintiff (in her capacity as both the beneficiary of the insurance policies and executor of the estate) and her ex-husband had, effectively, deprived the insurers of their contractual right (as stipulated in the insurance policies) to have an autopsy conducted on the body of the deceased and they were, therefore, entitled to deny liability. This case illustrates the difficulties inherent in conducting an independent review of a putative instance of drowning, where convincing and reliable forensic evidence and documentation are largely wanting; this being compounded by its occurrence in a foreign jurisdiction whose medico-legal practices differ substantially from that to which one is accustomed. It may even be said that the corpus delecti was destroyed, in this instance, by cremation. It is also unusual in that a de-facto finding of murder was made in a civil court (whose standard of proof is that of a balance of probabilities) and that this had, subsequently, spurred the police to undertake a criminal investigation for conspiracy to murder. In the event, the civil appeal was dismissed by the Court of Appeal, but no charge was laid against any of the suspects for want of sufficient forensic or investigative evidence of a criminal offence having been committed. ( info) |
18/130. Death by drowning? Geelong 1959 to 1974. This paper reviews the circumstances of 142 deaths by drowning which occurred in Geelong and district during the years 1959 to 1974. The effectiveness of safety nets and protective fences as a means of preventing the accidental submersion of young children in home swimming pools is questioned. Consumption of alcohol before submersion played a major role in the death of many adult males. Of males aged 26 years and over, 79% imbibed alcohol before death, and 57% had a blood alcohol concentration greater than 0.1% at autopsy. Of males aged 17 to 25 years of age, 25% imbibed alcohol before death and only half of these had a blood alcohol concentration greater than 0.1% at autopsy. The age preponderance for consumption of alcohol and drowning is opposite to that for fatal motor vehicular accidents (in these males aged 17 to 25 years more frequently have significant blood alcohol concentrations at autopsy than males aged 26 years and over). No female consumed alcohol before submersion. The writer suggests that the public, and in particular males aged 26 years and over, should be warned as forcibly against the dangers of "swimming and drinking" and "boating and drinking" as they are against the dangers of "driving and drinking". ( info) |
19/130. Hyperbaric oxygen therapy for a neurologically devastated child: whose decision is it? A recent case highlights one of the on-going and unresolved controversies in pediatric ethics: who makes treatment decisions for children. Children, by definition, do not have the maturity to make medical choices. Those decisions must be made for them. The issue remains by whom and on what standard those choices should be made. ( info) |
20/130. Use of the infant transwarmer mattress as an external warming modality in resuscitation from hypothermia. Normothermia must be established in drowning victims before death may be declared, as the myocardium may remain resistant to stimulation at subnormal temperatures, and complete neurological recovery from submersion associated hypothermia has been reported. A safe and effective method of external re-warming is described that may prove particularly useful in the paediatric population. ( info) |