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].
- Inspection (viewing).
- 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.