From Big Medical Encyclopedia

DROWNING — a type of the violent death coming at immersion of the person in water (is more rare other liquid) and caused by an acute disorder of functions of the vital systems of an organism (c. N of page, breath, blood circulation) under the influence of an aqueous medium. Resuscitators carry to drowning without having finished - shiysya in connection with a complex of sharply coming life-threatening disturbances of activity of an organism resulting from immersion of the person or his head or the person in water (other liquid) and fillings of respiratory tracts with it complicating rendered by medical aid or at all the organism stopping gas exchange with the air environment.

At. can occur during accidents of sea, river crafts and other watercrafts, during the falling of the air ship in water, at natural disasters, as a result of accidental falling in water, during the occupations aquatics, etc. However much more often it occurs during bathing in open reservoirs. According to the International amateur federation of swimming, in the world 250 — 300 thousand people annually sink. And more often persons of young age perish, the majority from to-rykh (70 — 90%) were able to swim.

Among the numerous reasons At. a specific place is held an emotional factor — fear (many researchers consider it the first phase of drowning) and water temperature. Fear — the powerful mental stress factor causing deep disturbances of psychomotor and other functions of an organism up to development of Ekhmotsio-nalny shock (see. Emotional stress). Emergence of sensation of fear in water is often connected not with real, and with the imaginary danger caused by personal uncertainty since the body of the person has the sufficient buoyancy allowing at a certain readiness and skill to make not only dynamic, but also static swimming, keeping on water in horizontal and vertical provisions.

Low water temperature at certain conditions of an organism (tendency to vasomotor spasms, an allergy to cold, etc.) causes a spasmodermia and lungs, long reduction of respiratory muscles that leads to acute disorders of breath and cordial activity, the anemia of a brain which is shown a state, unconscious or close to it (see the Syncope). At bystry entry or falling into water at almost healthy person the collapse (see) and the holodovy shock leading to bystry immersion of a body in water, and sometimes and by death can develop. Similar reactions can develop not only in cold (temperature lower than 16 — 18 °), but also rather warm water (22 — 26 °) when its temperature considerably differs from a tekhm-peratura of the body excited, e.g., with stay in the sun or as a result of an exercise stress.

At. can be fulminating and connected with irritation water of a mucous membrane of back departments of a nose (a nazokardialny reflex), a guttural nerve (a laringokardialny reflex), an acoustical nerve (so-called otogenic option of drowning). The reasons At. can become also inability to float, the general physical overfatigue, various painful states, a mechanical

injury at a diving, disturbance of cordial activity as a result of a prelum of abdominal organs, the shift of a liver, a stomach, intestines, change of a position of a diaphragm, development of a collapse in connection with a prelum of peripheral vessels, aggravated with hydrostatic pressure at a depth of St. 1V2 — 2 m. Pressure upon a stomach can lead to regurgitation and aspiration of food masses. Special danger is constituted by bathing in alcohol intoxication and a hangover.

Risk factors are the high speed of a current of water, existence of whirlpools, the key sources which are sharply changing water temperature on the limited site storm, a possibility of collision with watercrafts and having semi-sunk-shimi objects, etc.

To considerable decrease in risk At. not only in usual, but also extreme conditions promote education at the person of strong-willed qualities and a hardening of an organism.

At. conditionally subdivide on true, asphyxial (or so-called dry) and syncopal. Under true At., on a cut 30 — 35% of all cases of drowning are necessary, understand its such type when the expressed picture of filling of respiratory tracts and air cells by water, water intrusion in blood with the phenomena of hemodilution, hemolysis (see), disturbances of the vodnosolevy balance (see the Water salt metabolism) causing fibrillation of heart is observed (see Arrhythmias of heart). Most often it At. occurs in warm water, at a weak reflex of a throat, and also in alcohol intoxication.

Asphyxial type U., according to various researchers, makes from 45 to 61% of all cases of drowning. It is characterized by symptoms of the acute hypoxia (see) caused by closing of respiratory openings with water and development of a resistant reflex spasm of a throat owing to irritation of her receptors with water. Degree of fullness of respiratory tracts liquid in these cases influences a little a pathogeny and a thanatogenesis since liquid gets into them only in the preagonal period when due to terminal braking of c. the N of page and oppression of reflex activity weakens a spasm of a throat.

At a syncope flax type U. (15 — 25%) the death of the person (it is not possible to save it, as a rule) comes sharply from the termination of cordial activity in connection with emergence of cardiovagal reflexes (see. Vagus nerve).

Such division is conditional since reflects only extreme types U., does not open an etiology and a pathogeny At. in general, does not consider simultaneous action of several reasons, owing to-rogo diverse passage types are possible At. with absence bright patomorfol. signs.

Initial acute functional frustration at At., as a rule, have noticeable no pestilence foul. manifestations. Besides usually they are disguised patol. drowning, and its penetrations into an organism happened the changes resulting from closing of respiratory tracts Wednesday in a cut. Assessment of these changes is also the cornerstone court. - medical diagnoses U.

Harakter and degree morfol. changes depend on structure and the mechanism of water intrusion in airways, lungs, blood, a lymph and internals. Getting into a nasopharynx, water causes a reflex spasm of a throat at the expense of what it comes to paranasal sinuses (see), and through Eustachian tubes can get into a tympanic cavity (see). During this period of aspiration of water practically does not occur. The tussive reflex defines short exhalations, and the subsequent reflex breaths at the closed glottis lead to development of acute emphysema of lungs with disturbance of an elastic framework of alveoluses, a rupture of capillaries, developing of hemorrhages. The spasm of a throat is longer, the bigger amount of water comes to paranasal sinuses, emphysema of lungs is more sharply expressed and displays of a hypoxia are brighter.

During the opening of a glottis water, directing in a trachea and bronchial tubes, meets an obstacle of air in so-called dead space and, mixing up with it and the slime which is plentifully emitted during a protective bronchospasm forms resistant small-bubbling white foam. The involuntary respiratory movements in water after ultraboundary breath holding as a result of irritation of a respiratory center are created by the soaking-up effect, and water, forcing out air, gets into lungs.

At At. in the sweet water having in comparison with a blood plasma more low osmotic pressure (see) the considerable soaking-up surface of lungs defines transition of a large amount of water from lungs in a blood channel that leads to a hypervolemia (see Blood) with the expressed hemodilution, hemolysis (see), a hyperpotassemia (see) and a hypoproteinemia (see the Proteinemia). Since sweet water destroys surfactant of alveoluses (see Surfactant), the atelectases (see) which are the reason of the shunting of blood aggravating an anoxemia (see the Hypoxia) and acidosis develop (see). A part of the air which is forced out from alveoluses through the damaged walls of vessels gets into a blood channel, quite often forming air emboluses in pulmonary veins, the left half of heart and an aorta (see the Embolism). The hypervolemia, increase in venous pressure and the accruing decompensation of a right ventricle of heart promote development of an acute fluid lungs (see), and the accruing hyperpotassemia leads to fibrillation of ventricles of heart.

At At. in the sea water having higher than the blood plasma, osmotic pressure, electrolytes of aspirirovanny liquid diffuse in plasma, and water and blood proteins pass into alveoluses. At the same time the hypovolemia (see Blood), an osmotic pachemia, wrinkling of erythrocytes, a gipergidriya of pulmonary fabric, and in cases of aspiration of a significant amount of water — a fluid lungs develops. Since at At. in sea water surfactant of alveoluses suffers to a lesser extent, extensive atelectases of lungs do not arise.

Volume aspirated at At. waters depends on its temperature (warm water is aspirated in bigger quantity), reflex irritability of upper respiratory tracts, intensity of respiratory movements and vital capacity of lungs. At At. in other liquids also their viscosity and toxicity matters. At the persons which got to water in unconsciousness (during an epileptic seizure, in a condition of an alcoholic coma, at a cranial moz-govoy to an injury, etc.) or being under the influence of drugs, alcohol, neuroleptics and other substances reducing an excitation threshold of c. the N of page, aspiration of water occurs in bigger volume, however its absorption in blood is slowed down.

Death from At. can come at any stage of immersion, and also immediately or later a nek-swarm time after extraction of the drowning person from water or independent rescue, it the fluid lungs, pneumonia (see), irreversible changes of c can be the cause. N of page, heart, kidneys, etc.

Success of assistance sinking in many respects depends on the correct assessment of circumstances At., helping to open its reason and, therefore, orienting to holding purposeful medical actions, to-rye can be successful even at approach of clinical death.

The help during the drowning. The volume of actions of the first medical aid depends on weight of a condition of the victim. If it is in consciousness and independent breath is kept, then the victim should be warmed and calmed (sedatives and tranquilizers are shown). If the victim is in unconsciousness, but independent breath is kept and regular pulse of satisfactory filling on peripheral vessels is defined, then it is necessary to exempt his thorax from the constraining clothes, to allow to breathe vapors of spirit of ammonia; it is possible to apply a way of twitching for language to activation of breath. For maintenance of passability of upper respiratory tracts of the victim stack sideways with lowered headfirst; in medical establishment enter an air duct into a trachea, and also by means of the thick probe evacuate contents of a stomach for the prevention of aspiration. Even in the absence of clear signs of frustration of pulmonary gas exchange (falloff of amplitude of respiratory movements and considerable increase of breath, cyanosis of skin and mucous membranes, symptomatology of a fluid lungs) inhalation of oxygen is shown (see. Oxygen therapy).

The victims who is in unconsciousness in the presence of signs of disturbance of breath and blood circulation (a frequent or infrequent pulse, frequent or a bradypnoea, motive excitement, cyanosis of skin) or in the absence of independent breath need to begin urgently an artificial respiration (see). Previously the finger wrapped by fabric clear an oral cavity and a throat of foreign bodys, emetic masses and slime, delete removable dentures. It is important not to waste time for attempts to remove all liquid from respiratory tracts since it is impracticable. Only at At. in sea water loss of several tens seconds on evacuation of liquid from lungs is justified, fresh water quickly comes to a blood channel. For removal of liquid from upper respiratory tracts and a stomach of the victim turn sideways and a palm or a fist vigorously press on epigastric area, monitoring the expiration of water from a mouth of the victim. After that it is put on a back and start carrying out an artificial respiration of companies in a mouth or a mouth in a nose. If at the same time from respiratory tracts water is emitted, it is necessary to turn the head of the victim aside and to raise his opposite shoulder. The artificial respiration needs to be continued to a complete recovery of consciousness.

If the victim has no pulse on large arteries, heartbeat, mydriatic pupils, skin pale or cyanochroic is not listened, along with an artificial respiration to it carry out an indirect cardiac massage (see). After removal from a condition of clinical death of the victim warm if temperature of his body is lower 30 — 32 °, and carry out massage of top and bottom extremities. Body temperature is maintained in limits 32 — 33 ° (moderate decrease in body temperature increases portability of a hypoxia of c. N of page).

Due to the danger of development of late complications of the victim after rendering the first medical aid it is necessary to hospitalize and observe in the conditions of a hospital not less 24th hour. The program of intensive observation in a hospital includes registration of a respiration rate, frequency and a rhythm of cordial reductions, consecutive measurements of the ABP, monitor observation (see), definition of a hemoglobin content, concentration of electrolytes, indicators of acid-base equilibrium and structure of blood gases, the hourly accounting of a diuresis.

Therapy in the conditions of a hospital is directed to fight against a hypoxia by means of inhalation of oxygen. Lack of effect of such therapy (at the victim cyanosis remains, tension of oxygen in an arterial blood does not rise higher than 50 — 55 mm of mercury.), and also disturbance of a respiratory rhythm and tachypnea (more than 40 dykhaniye in 1 min.) are indications to artificial ventilation of the lungs by means of automatic respirators (see. Artificial respiration). It is necessary to carry out artificial ventilation of the lungs 100% by oxygen with positive pressure at the end of an exhalation (+5, + 10 cm w.g.), what promotes a raspravleniye of alveoluses and by that to decrease in intake of neoksigeni-rovanny blood from system of a pulmonary artery in pulmonary veins. Early correction of a metabolic acidosis (drop intravenous administration of solution of hydrosodium carbonate), antihistaminic drugs are shown.

With a high venous and arterial pressure (see arterial hypertension, Hypertensia of a small circle of blood circulation) intravenously enter ganglioblokator and diuretics. At the low ABP appoint glucocorticoid hormones, a dopamine. Apply to improvement of metabolism and sokratitelny ability of a myocardium cardiac glycosides, Pananginum, cocarboxylase, redoxons, B1? B6 (vitamins enter separately). At emergence of fibrillation of ventricles of heart the defibrillation is shown (see). For prevention of an acute renal failure (see) carry out an artificial diuresis by lasixum after correction of a metabolic acidosis and hemodynamic frustration. For the purpose of prevention of wet brain (see Hypostasis and swelling of a brain) use a local hypothermia, enter corticosteroids and barbiturates. For prevention of development of inflammatory process in lungs parenterally appoint antibiotics of a broad spectrum of activity.

The orientation of therapeutic actions depends on in what water occurred At., in salty or fresh. So, at aspiration of sweet water and existence at the affected sharp cyanosis testimonial of an overload of the right half of heart, carry out urgent bloodletting (see). For bystry removal of products of hemolysis intravenously kapelno enter a mannitol; for the purpose of reduction of a hyperpotassemia — glucose with insulin; also early transfusion of whole blood is shown. At aspiration of sea water make up for a fluid loss the entered intravenously plasma substituting solutions, and also solutions of glucose and hydrosodium carbonate.

During rehabilitation a recurrence of heavy parenchymatous respiratory insufficiency is possible (see). Frequent complications at At. the fluid lungs and aspiration pneumonia is. In nek-ry cases the fluid lungs accrues extremely quickly and difficult gives in to therapy. The prevention of similar complications requires constant overseeing by parameters of breath of the victim, dynamics of acid-base balance (see) blood. Quite often there is also wet brain, the acute period to-rogo is characterized by development of spasms (see), pyramidal insufficiency (see. Pyramidal system). For the prevention of edematization of a brain appoint corticosteroids, barbiturates. In the remote period as a result of hypoxemic injury of a brain can arise an ataxy (see) and a myoclonia (see) cerebellar and spinal type. Their treatment is similar to that at the patients who transferred disturbance of cerebral circulation (see the Stroke). Special attention in the remote period should be paid to prevention and treatment intellektual-but-mnesticheskikh frustration.

Drowning in the medicolegal relation. Among the persons which underwent At., accidents prevail, however take place of suicide and murder in this connection corpses of the persons who died from drowning are subject obligatory court. - to a medical

research. Court. - medical diagnosis At. as causes of death is based on complex assessment morfol. changes and results of laboratory researches. Sometimes it presents considerable difficulty since the found changes are not always clear and evidential, especially at a research of a corpse, is long being in water and with the expressed putrefactive changes.

To external signs At., revealed at an outside research of a corpse, refer pallor and temperature of skin, low in comparison with air temperature, so-called «goosellesh», resistant pinkish-gray small-bubbling foam around a mouth and a nose, lead and cyanotic livors mortis with indistinct, as if indistinct contours. The specific shade and intensity of coloring of livors mortis depend on extent of cultivation of blood liquid, in a cut occurred At. Therefore at insignificant or total absence of hemodilution (e.g., at At. in sea water or syncopal type U.) livors mortis have usually blue-crimson coloring. Through a nek-swarm time after death from At. livors mortis can get a pinkish shade due to saturation of blood the oxygen getting through matserirovanny epidermis.

At an internal research of a corpse are expressed or pallor of hypodermic cellulose and skeletal muscles, a sharp plethora of veins and abdominal organs prevail, in pleural and belly cavities transudate (Moro's sign) is found, acute swelling of lungs with the phenomena of a giperaeriya is noted, is more rare — a gipergidriya and hypostasis, prints of edges in posterolateral departments of lungs are visible and pale indistinct hemorrhages under a pleura (Rasskazov's spots — Lukomsky — Paltaufa), small hemorrhages in lungs against the background of their anemia — «marble lungs», in a bosom of the main (wedge-shaped) bone of a skull (see Paranasal sinuses) liquid with elements of dwelling of the environment of drowning (Sveshnikov's sign), in a chest channel is found (see) erythrocytes (Isaev's sign) come to light, hemodilution is noted, in the left half of heart air emboluses, and in a stomach and a duodenum — a significant amount of water are found. At At. in sea water tissue of lungs from a surface and on a section motley, with the light and dark-violet centers; hemorrhages under a pleura and in lungs, as a rule, multiple, large (to 4 cm in the diameter), dark red color. At gistol. a research sharp expansion of alveoluses, and in small vessels — accumulation of not changed erythrocytes is defined.

The greatest value for court. - medical diagnoses At. and clarifications of a thanatogenesis have the signs making a so-called diagnostic tetrad of Sveshnikov — Isaeva: liquid in a bosom of the main bone, acute swelling of lungs, an air embolism of the left half of heart, existence of erythrocytes in a chest channel (see Thanatology).

Pallor of skin and soft tissues of a corpse speaks arising at At. spasm of peripheral arteries and arterioles. The vasomotor spasm, and also the raised thermolysis as a result of high thermal conductivity of water cause the low temperature of skin. The so-called goosellesh is connected with reduction of the muscles straightening hair. Moro's sign is caused by posthumous transudation of liquid from lungs, a stomach and intestines owing to an irreversible razvolokneniye of vascular membranes and disturbance of permeability. Hemorrhages under a pleura and in tissue of lungs arise in places of ruptures of small vessels, their coloring and clearness of borders depend on degree of hemodilution. The retrograde throwing of erythrocytes to the chest canal is caused by the acute insufficiency of its valves caused by venous stagnation and build-up of pressure is preferential in venas cava. Liquid in went. - kish. a path at At. arrives as a result of involuntary swallowing. At the same time it is important to establish in the sudebnosledstvenny relation its identity with Wednesday, in a cut there was U. V a case At. in the navigable reservoirs contaminated by oil products determine the content of oil products in liquids of a body (oil test of Bystrov).

The majority of the laboratory methods offered for diagnosis At., it is based on detection of distinctions physical. - chemical properties of the arterial and venous blood received from cardial cavities, an aorta and the lower vena cava as in arterial system blood is exposed to bigger cultivation. Define a freezing point (see Kriometriya), the content of residual nitrogen (see residual nitrogen), a ratio of volume of erythrocytes and plasma (see Gematokritny number), conductivity (see Conductivity of biological systems), osmotic pressure (see), hydrogen ion exponent (see) arterial and venous blood. However these methods are reliable only at true type U. and a research of the corpse taken from water through short time later At. Therefore they did not find broad application in court. - medical practice. The exception is made by

the test consisting in drawing on filter paper of drops of blood from the right and left half of heart: emergence of a pale yellow

aura and bigger diameter of a spot are signs of hemodilution.

The greatest distribution in practice court. - medical examinations were received by the method based on detection in the blood and internals of kvartssoderzhashchy particles (psev-dogshankton) and diatomic seaweed (phytoplankton) having extremely strong armor from silicon dioxide that ensures their long safety in the studied objects. The proof At. detection in kidneys, a liver, marrow of long tubular bones and breasts, vascular textures of cerebral cavities of several tens armors of diatoms, identical subjects to their types is, to-rye are in a reservoir where occurred At. Detection of separate diatoms is not evidential since it can be caused by their hit in objects from air in the course of a preparation of material to a research, and also stay them in an organism still to At., where they can get with food stuffs or from inhaled air. Proof of true and asphyxial types U. also detection in liquid from a bosom of the main bone a dispute of seaweed, live infusorians and phytoplankton is (see Plankton, in the medicolegal relation).

Court. - medical recognition a syncope of lny type U. is based on establishment of conditions and scenes, on detection of signs of quickly come death — pallor of skin, an anemia of lungs (owing to a skin and visceral reflex), overflow by blood of venous vessels and abdominal organs.

At syncopal and asphyxial types U. the corpse can not plunge on a bottom, and float at a water surface whereas at true At., when lungs also went. - kish. a path are filled with water, the corpse plunges on a bottom and only through a nek-swarm time emerges owing to formation of putrefactive gases.

Important court. - medical value has establishment of the mechanism of the damages found on the corpse taken from water. Intravital damage can be sustained both before hit in water, and at blow about water or a bottom of a reservoir in a time of fall or a jump from big height, swimming under water, and also as a result of blows by parts of the water transport. At the same time there can be bruises, wounds, grazes, ruptures of muscles, internals, tympanic membranes, fractures of bones, fractures and dislocations of cervical, upper chest, is more rare than lumbar vertebrae. In the agonal period At. at the convulsive movements damages from blows about the objects which are in a reservoir are possible; damages of brushes and fingers of hands about an uneven relief of a bottom are frequent. Posthumous damages can be caused by drawing of a corpse on an uneven stony bottom by the strong current, blows of vessels, their screws on the emerged corpse, and also can be caused by fishes, crayfish, mollusks, etc.

In court. - it is extremely important to medical practice to differentiate At. from stay of a corpse in water, a cut can take place at an instsenirovaniye At. as accident or in connection with concealment of a corpse. At a research of a corpse in a case At. find signs as At., and stay of a corpse in water whereas in other cases — only signs of stay of a corpse in water, to the Crimea carry: humidity of clothes, a hair and skin, availability on them of silt, sand, seaweed, etc., low body temperature in comparison with an ambient air; pinkish shade of livors mortis, puffiness of mucous membranes of eyes; maceration of skin with a consecutive loosening of epidermis (a so-called beef-steak hand), peeling (formation of so-called gloves of death) and, at last, its removal causing emergence of a so-called well-cared hand. Maceration of skin of a pilar part of the head leads to a hair loss. Intensity and speed of maceration depend on water temperature, existence of a current, its speed, etc.

Bibliography: Avdeev M. I. Rate of sou

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