ACKNOWLEDGMENT

I, Ahmad Syahir Bin Ismail, 5th semester medical student of Universitas

Udayana with NIM no: 1102005227 would like to express my prayers to the Lord
for successfully completing my Elective Study on task on topic titled
Characteristic and finding examination in patient death cause off drowning
Firstly, I would like to express my heartiest thank you to my supervisor Dr Ida
Bagus Putu Alit, head of the forensics department at Denpasar's Sanglah Hospital
for assisting me in my paper work and also guiding me through this proposal
writing as well as developing a good understanding of the topic with me. He has
been very helpful in providing assistance in finding journals for the topic and
leading me through the successful completion of this proposal.
Secondly, the benefit that I have gained through this whole journey of this
proposal is I have a chance to explore more about the field of the topic I have
researched on. In addition, I have learned how to take full responsibility of my
own research paper. Overall I have learnt many wonderful and important facts
about this topic.
Thank you.
Denpasar, February 2014
BY,

..
(AHMAD SYAHIR BIN ISMAIL)
NIM 1102005227

CONTENTS

1. ACKNOWLEDGEMENT..i
2. INTRODUCTION..1
3. LITERATURE REVIEW.3
4. CONCEPTS7
5. HYPOTHESIS7
6. METHODS OF RESEARCH8
7. CONCLUSION..11
8. REFFERENCES.12
9. APPENDIX.13

CHAPTER I
INTRODUCTION

1.1 Background
Bali is an island and the smallest province of Indonesia. It is located at the
westernmost end of the Lesser Sunda Islands, between Java to the west and
Lombok to the east, and has its capital of Denpasar at the southern part of the
island. With a population of 3,890,757 in the 2010 census and currently 4.22
million, the island is home to most of Indonesias Hindu minority. Bali is also the
largest tourist destination in the country and is renowned for its highly developed
arts, including traditional and modern dance, sculpture, painting, leather,
metalworking, and music. Beside that tourist come here because of the beauty of
this island. They like to surf, swim and some just like to enjoy the view.
However in the recent year number of patient death because of drowning keep
increasing among the tourist. Maybe because lack of knowledge and some
overconfident tourist they just take thing for granted about their safety. Sometimes
parent attitude didnt pay attention about their child that are playing at the edge of
the island increase probability of their child to get into this incident.. So in this
paper because of higher number of death of patient cause by drowning among the
tourist I would like to do a paper title characteristic and finding examination in
patient death cause of drowning.

1
1.2 Problem Identification
Problems which will be reviewed in this paper are as follows:
1. What is the characteristic and finding examination of drowning patient?
2. How drowning can cause death?
3. What is the mechanism of death cause by drowning?
4. How drowning is related with asphyxia?
1.3 Aims
Objectives to be achieved in this paper are as follows:
1. To know the characteristic and finding examination in a drowning patient.
2. To know how drowning can lead to asphyxia and cause death.

1.4 Benefits
Benefits to be achieved in this paper are as follows:
1. Increase knowledge of people how drowning cause asphyxia can lead to
death
2. Give overview of characteristic and physical examination of drowning
patient
3. Differentiate patient die because of drowning and other cause

CHAPTER 2
LITERATURE REVIEW

2.1 Basic definition of drowning and mechanism of death

From World Health Organisation (WHO) definition of drowning is the
process of experiencing respiratory impairment from
submersion/immersion in liquid. Drowning outcomes are classified as
death, morbidity and no morbidity.

Drowning occurs when water comes into contact with the larynx starting
with this 4 step

After an initial gasp, there is an initial voluntary breath holding.

This is followed by spasm of the larynx and the development of

hypoxemia (hypo=low + ox=oxygen + emia=blood), or decreased levels of
oxygen in the bloodstream.

Lack of oxygen causes aerobic metabolism to stop, and the body becomes
acidotic. If not corrected quickly, the lack of oxygen in combination with
too much acid may lead to problems with the electrical conduction system
of the heart (cardiac arrest) and lack of blood supply to the brain.

As body function declines, aspiration may occur as the larynx relaxes

allowing water to enter the lungs. However, up to 20% of drowning
victims have persistent spasm of the larynx, and no water is aspirated (this
was formerly known as "dry" drowning).

2.2 Salt vs. fresh water drowning

In the lung, the breathing tubes (trachea, bronchi, bronchioles) branch into
smaller and smaller segments until they end in an air pocket called an
alveolus (plural alveoli). This is the part of the lung where air and red
blood cells in capillary blood vessels come near enough to allow the
transfer of oxygen and carbon dioxide between the two. Alveoli are

covered with a chemical called surfactant that allows the air pocket to
open and close easily when breathing occurs.
When fresh water enters an alveolus, it destroys the surfactant and
causesthe alveoli to collapse, unable to open with breathing. A ventilationperfusion mismatch occurs in which the body sends blood to parts of the
lung that lack oxygen, resulting in a decrease in the concentration of
oxygen in the blood.
Salt water doesn't destroy surfactant, rather it washes it away and damages
the membrane between the alveolus and the capillary blood vessel. One
again, the body sends blood flow to areas of the lung that aren't able to
provide it oxygen, and hypoxemia occurs.
Regardless of the type of water, lung function is compromised, because of
the lack of surfactant, and hypoxemia occurs. In some circumstances,
electrolyte abnormalities may occur with fresh water drowning.

4
2.3 Signs Of Immersion

the skin becomes somewhat opaque and wrinkled. known as

washerwomans fingers, develop after a few hours in cold water.

After a few days, this macerated skin will begin to separate and,

usually within 12 weeks the skin will peel off the hands and feet.

another early sign of immersion is cutis anserina or gooseflesh, d/t

contraction of the erector pili muscles.

However, this is partly due to cold (and may be seen in refrigerated

bodies) and partly due to rigor mortis.

Cutis anserina is not a specific sign of immersion.

in average temperate conditions a body immersed in water will decompose

at about half the speed of one left in air.

After about a week, the body will be bloated and the face, abdomen and
genitals will be distended with gas

As the body is moved by the flow of the water, contact with rocks, piers
and many other underwater obstructions can cause damage.

2.4 Macroscopic Examination

At external examination
the plume of froth at the mouth and nostrils can be considered as a valuable
indication. The pitfall is that this finding is non-specific, quite transient and
can only be found in fresh drowned bodies. Moreover, all other signs are
immersion signs and not pathognomonical for drowning.
At internal examination
Following thoracic findings can provide useful information: lung emphysema and
oedema aquosum indentations of ribs in lungs, Paltaufs spots, froth in the
trachea, elevated lung weights and pleural effusions. Hadley and Fowler found
that elevated lung and kidney weights are the result of both asphyxiation
5
and the aspiration of water, whereas increased spleen and liver weights in
drowning victims were only due to the asphyxiation effect However, a small,
anaemic spleen was hypothesized to be a post-mortem phenomenon.A
significantly higher lungheart weight ratio was found in fresh-/saltwater
drowning victims compared with other asphyxiation fatalities. In addition, a

significant difference was found between salt- and freshwater drowning cases: due
to the hyperosmolar properties leading to plasma leaking into alveolar spaces,
more pleural fluid is produced in the saltwater drowning casesInspection of the
stomach can reveal Wydlers sign (swallowing of water) or even the Mallory
Weiss syndrome (oesophageal mucosal tears)

2.5 Microscopic Examination

Classical histological examination (hematoxylin eosin staining) shows obvious
intra-alveolar oedema and dilatation of the alveolar spaces with secondary
compression of the septal capillaries. Delmonte and Capelozzi could differentiate
between other modes of asphyxiation In addition, an increase of macrophage
subtypes (myelomonocyte subtypes) in the alveolar-intracapillary compartment by
means of an immunohistochemical method was demonstrated .However, the
interpretation of these tests is quite difficult. Several years ago, a scanning
electron microscope study pointed out to distinguish chronic emphysema from the
acute emphysema of drowning. However, when both emphysema aquosum and
chronic emphysema coexist, the diagnosis becomes difficult to establish. Here as
well post-mortem alterations will hamper a correct interpretation

CHAPTER 3
CONCEPT AND HYPOTHESIS

3.1 Concept
Investigation of bodies recovered out of water comprises an important proportion
of the medico-legal requests. However, the key question whether the victim died
due to true drowning can frequently not easily be solved. In addition, the
diagnosis of hydrocution (any poorly diagnose death in water but not due to
drowning) is even more difficult. In this manuscript, a review of reported
diagnostic methods is discussed in order to provide guidelines, which can be used
in current forensic practice. In particular, the (dis)advantages of various biological
and thanato chemical methods, described in literature during the last 20 years, will
be confronted with the classical techniques such as the detection of diatoms and
algae. Indeed, the diatom test is still considered as the golden standard. The
ideal diagnostic test as definite proof for drowning still needs to be established. At
present, the combination of the autopsy findings and the diatom test is a good
compromise in arriving at a conclusion
3.2 Hypothesis
The study was carried out to investigate the presence of diatoms in the tissues
(lungs and sternum) of subjects who died from drowning. Also investigator study
microscopic and macroscopic autopsy finding in drowning patient.

CHAPTER 4
METHODS OF RESEARCH

4.1 Design of research

This study is categorized as descriptive study. Descriptive study is a research
aimed at doing just that in the description of the phenomenon was found, but
made no attempt to find out why this phenomenon can occur. This is a one to one
interaction study with the groups of people or clearly known as cross sectional
study. This cross sectional study involves surveys, interviews and checklist given
to participants by researcher..
4.2 Population and sample of research
4.2.1 Population of research
1) The target population is the all patient come to RSUP Sanglah because of
drowning from January 2013 to 2014 alive or death
2) The population terjangkau of this study are cardaver that are autopsy
diagnosed of death because of drowning in January 2013 to 2014
4.2.2 Criteria of sample
The investigator will be studying the characteristic and examination finding of
drowning patient. Two groups of cadavers that underwent an autopsy at the
Institute of Forensic Medicine RSUP Sanglah were included in the study. Group A
comprised 45 individuals who died from causes other than drowning, whereas
Group B comprised 20 bodies which had been recovered from water. The
extraction of the diatoms was performed by incubation of samples in nitric acid
for 48 hours at 60C. The body are examined. Internal and external.
8

4.2.3 Method of sampling for research

The sampling technique used is simple random sampling. Investigator will choose
any cardaver because of drowning in forensic department. Investigator used
record from forensic department and select randomly from the name list of
available cardaver
4.3 Research variable
Manipulated variable :Diatom presence and examination finding
Responding variable : cadaver death because of drowning and other than
drowning
Fixed variable : Duration of death of cadaver
4.4 Data collecting method and analysis
Data used in this paper are secondary data from forensic department medical
record in January 2013 to January 2014
.
4.5 Place and time of research
Populasi Target

The research was conducted at Forensic Department of RSUP Sanglah from

January 2013 to January 2014
Populasi Terjangkau

Consecutive Sampling
Sampel
Kriteria Inklusi
Kriteria Eksklusi
Diatom and
examination finding

4.6 Schematic Diagram of sampling technique

Data

Analisis Data

Diagram 1

10

CHAPTER 5
CONCLUSION

As a conclusion, Bodies may be found after immersion in either fresh or

salt water, but proof that death was due to drowning may constitute one of the
most difficult problems in forensic medicine. If the circumstances of death are
known, the diagnosis of drowning will not present any difficulty. However, when
a body is found in water and no circumstantial details are available of how it got
there, the case may pose a difficult problem. In some cases, the diagnosis of
drowning cannot be established for lack of definite signs; hence one has to draw
conclusions on the basis of exclusion of other causes of death. In such situations
every detail of the case must be considered with an open mind. A fatal accident in
the bathtub is frequently associated with an epileptic attack, an episode of acute
coronary insufficiency and alcohol or drug intoxication. In such a death also
minor injuries from a fall may be present. The body should be examined for
injection marks and electrical burns. Past history of the decedent must be
reviewed. In addition to the evaluation of the internal injuries, the role of any
natural disease condition in the collapse of the person found in the water should
be properly assessed. Adequate microscopic and toxicological studies must be
made. Sections of the lungs from drowning cases show evidence of acute
emphysema with rupture of many of the alveoli. The analyses for alcohol should
be done routinely. Analyses for drugs that the decedent was known to be using
also should be a part of the investigation especially in a bathtub death and in
suicide

11

REFFERENCES

1. J.A. Hadley, D.R. Fowler, Erratum to Organ weight effects of drowning and
asphyxiation on the lungs, liver, brain,
heart, kidneys and spleen, Forensic Sci. Int. 137 (2003) 239246.
2. Davis, J H. Bodies Found in Water, Am. J. Forensic Med. Pathol. 1986 ,
p. 291 - 297.(good discussion of the investigative approach to these
cases).
3. Fisher R S, C C Thomas, Springfield, Illinois, 1973, p. 351 - 366.
4. Drowning in the Essentials of Forensic Medicine, 3rd edition, by Polson
C J and Gee, D J, Pergamon, Oxford, 1973, p. 440 - 466.
(the best and most comprehensive discussion in a British text book).
5.Copeland A R, An Assessment of Lung Weights in Drowning Cases, Am.
J. Forensic Med. Pathol, 1985, 6, 301-304.
6. B.-L. Zhu, L. Quan, D.-R. Li, M. Taniguchi, Y. Kamikodai, K. Tsuda, M.Q.
Fujita, K. Nishi, T. Tsuji, H. Maeda,
Postmortem lung weight in drownings: a comparison with acute
asphyxiationand cardiac death, Legal Med. 5 (2003)
2026.
7. K. Puschel, F. Schulz, I. Darrmann, M. Tsokos, Macromorphology and
histology of intramuscular haemorrhages in
cases of drowning, Int. J. Legal Med. 112 (1999) 101106.
8. A.M. Abdallah, S.A. Hassan, M.A. Kabil, A.-E.E. Ghanim, Serum strontium
estimation as a diagnostic criterion of the
type of drowning water, Forensic Sci. Int. 28 (1985) 4752.

ABSTRACT

Drowning is a major global public health problem. Effective prevention of

drowning requires programmes and policies that address known risk factors
throughout the world. Surveillance, however, has been hampered by the
lack of a uniform and internationally accepted definition that permits all
relevant cases to be counted. To develop a new definition, an international
consensus procedure was conducted. Experts in clinical medicine, injury
epidemiology, prevention and rescue from all over the world participated in
a series of electronic discussions and face-to-face workshops. The
suitability of previous definitions and the major requirements of a new
definition were intensely debated. The consensus was that the new
definition should include both cases of fatal and nonfatal drowning. After
considerable dialogue and debate, the following definition was adopted:
Drowning is the process of experiencing respiratory impairment from
submersion/immersion in liquid. Drowning outcomes should be classified
as: death, morbidity, and no morbidity. There was also consensus that the
terms wet, dry, active, passive, silent, and secondary drowning should no
longer be used. Thus a simple, comprehensive, and internationally
accepted definition of drowning has been developed. Its use should support
future activities in drowning surveillance worldwide, and lead to more
reliable and comprehensive epidemiological information on this global, and
frequently preventable, public health problem.