Drowning: Examination

If near drowning occurs because of an accident, the Glasgow Coma Scale should be performed to assess level of consciousness:

Traumatic brain injury (TBI). Glasgow Coma Scale Unconsciousness
Mild TBI 13-15 points up to 15 minutes
Moderately severe TBI 9-12 points up to one hour
Severe TBI 3-8 points > 1 hour

Glasgow Coma Scale, GCS). This contains the following criteria:

Criterion Score
Eye opening spontaneous 4
on request 3
on pain stimulus 2
no reaction 1
Verbal communication conversational, oriented 5
conversational, disoriented 4
incoherent words 3
unintelligible sounds 2
no verbal reaction 1
Motor response Follows prompts 6
Targeted pain defense 5
untargeted pain defense 4
on pain stimulus flexion synergisms 3
on pain stimulus stretching synergisms 2
No response to pain stimulus 1

Assessment

  • Points are awarded for each category separately and then added together. The maximum score is 15, the minimum 3 points.
  • If the score is 8 or less, a very severe brain dysfunction is assumed and the there is a risk of life-threatening respiratory disorders.
  • With a GCS ≤ 8, airway protection must be considered.

TBI includes:

  • Scalp injuries,
  • Bony fractures
  • Dura injuries
  • Intracranial lesions

This is followed by a comprehensive physical and neurological examination:

  • General physical examination – including blood pressure, pulse, body temperature, body weight, body height; furthermore:
    • Inspection (viewing).
      • Head/skull [due topossible symptoms (grade 1): swelling, bleeding on skull].
      • Skin and mucous membranes [differential diagnostic signs: tongue bite/urination?]
      • Abdomen (abdomen)
        • Shape of the abdomen?
        • Skin color? Skin texture?
        • Efflorescences (skin changes)?
        • Pulsations? Bowel movements?
        • Visible vessels?
        • Scars? Hernias (fractures)?
    • Auscultation (listening) of the heart [due topossible symptom (grade 1): disturbances of heart rate].
    • Auscultation of the lungs [due topossible symptom (grade 1): disorders of respiration]
    • Palpation (palpation) of the abdomen (abdomen) (pressure pain?, knock pain?, cough pain?, defensive tension?, hernial orifices?, kidney bearing knock pain?) [due topossible symptoms (grade 1): nausea (nausea), vomiting].
  • If necessary, ENT medical examination [due topossible symptom (grade 1): hearing loss (hypacusis)].
  • Neurological examination – including checking reflexes, pupillary response and cranial nerve function [due topossible symptom (grade 1):
    • Amnesia (memory lapse).
    • Cephalgia (headache)
    • Seizure
    • Unconsciousness lasting a short time
    • Subsequent drowsiness and deceleration
    • Visual disturbances such as diplopia (double vision, double images).
    • Vertigo (dizziness)
    • Confusion (also instead of unconsciousness).

    due topossible symptoms (grade 2): neurological disorders such as reflex changes, pupil changes, paresis (paralysis)] [due todifferential diagnoses (if there is no definite evidence of an accidental event):

    • Apoplexy (stroke).
    • Basilar artery thrombosis – occlusion of a basilar artery of the brainstem associated with severe neurologic damage.
    • Chronic subdural hematoma – hemorrhage between layers of the meninges that can lead to various neurological symptoms.
    • Coma vigile (akinetic mutism) – muteness with general inhibition of motor functions, which is mainly conditioned by psychiatric diseases or injuries/tumors of the brain
    • Epilepsy
    • Increased intracranial pressure
    • Brain abscess – encapsulated collection of pus in the brain.
    • Brain contusion (brain contusion)
    • Brain mass hemorrhage
    • Cerebral sinus thrombosis – occlusion of a venous cerebral blood duct.
    • Brainstem hemorrhage
    • Brainstem infarction
    • Meningoencephalitis – combined inflammation of the brain (encephalitis) and meninges (meningitis).
    • Subarachnoid hemorrhage – bleeding between the cobweb and the surface of the brain; in 75-80% of cases, the cause is an aneurysm (bulging of an artery)]
  • If necessary, urological examination [due todifferential diagnosis (if there is no definite evidence of an accidental event): coma uremicum (coma caused by uremia (occurrence of urinary substances in the blood above the normal values))]

Square brackets [ ] indicate possible pathological (pathological) physical findings. Postmortem, the following findings can be identified in death by drowning:

Typical drowning

  • External necropsy:
    • Foamy fungus – swells from the mouth and nose; it is formed from fluid, bronchial secretions, and residual air from the alveoli (air sacs in the lungs)
  • By autopsy:
    • Sehrt gastric mucosal tears – especially at the entrance to the stomach, caused by vomiting of swallowed water.
    • Water in the gastrointestinal tract (gastrointestinal tract).
    • Wydler’s sign – the stomach contents are three-layered: foamy at the top, liquid in the middle, solid at the bottom.
    • Pulmonary findings:
      • Elasticity of the lung tissue is decreased
      • Lung lobes are overinflated and dry and massively swollen
      • Paltauf spots (suffocation bleeding).

Atypical drowning

  • By autopsy:
    • Paltauf’s stains (washed-out hemorrhages of the visceral pleura in death by asphyxiation due to drowning) and Wydler’s sign may be absent or mild.Wydler’s sign: This is done by removing the stomach contents and placing them in a beaker. After standing for some time, a characteristic three-layered pattern, the Wydler sign, can be observed: At the top is a foamy phase, in the middle is a liquid phase and at the bottom of the glass is a solid phase
    • If necessary, the cause of the atypical drowning can be found.