Back hemorrhage in bath-related deaths: Insights into the mechanism of bath-related deaths.

Forensic pathologists often encounter difficulties while diagnosing bath-related deaths owing to a lack of specific findings for determining the cause. This study reports the characteristic findings noted during autopsy associated with bath-related deaths. The subjects included individuals found deceased in water-filled bathtubs. Originally, a "bathtub death" was defined as a case of drowning in a bathtub without a known cause despite complete investigation including a complete autopsy and examination of the death scene. We also excluded cases with ethanol and/or high drug concentrations in the blood from "bathtub death" cases. Muscular hemorrhages around the scapula were the most common in cases of accidental drowning (72.7%). The frequency of muscular hemorrhages around the scapula was low in cases involving bathtub deaths (11.1%) and natural disease. Subcutaneous hemorrhages in the back were the most frequent in cases of bathtub death (88.9%), followed by accidental drowning (81.8%). The frequency of subcutaneous hemorrhages in the back was low in cases involving suicide and natural disease. The presence of subcutaneous hemorrhages in the back without muscular hemorrhages around the scapula were strongly associated with bathtub deaths (Fisher's exact test, P < 0.0001; sensitivity, 0.84; specificity, 0.91). Subcutaneous hemorrhages were the most frequent in the waist (68.8%), followed by the upper back (50%). Subcutaneous hemorrhages in the back without muscular hemorrhages around the scapula indicated that the deceased had hit their back on falling from a standing position after experiencing disturbances of consciousness. We found the occurrence of orthostatic hypotension while getting out of the bathtub to be the most likely cause for these autopsy findings. Subcutaneous hemorrhages in the back without muscular hemorrhages around the scapula is a characteristic finding of "bathtub deaths". Although this was a preliminary study, the presence of this finding may aid in clarifying the mechanism of bath-related deaths.

Association between sudden unexpected deaths in bathtubs and ambient temperature among elderly Japanese adults: A time-series regression study.

BACKGROUND: Sudden unexpected deaths in bathtubs among elderly Japanese adults occur predominantly during the cold season. This study investigated the relationship between these deaths and bathing day temperature among elderly adults in Tokyo. METHODS: Data for 1408 cases of bath-related deaths from January 1 to December 31, 2015 were obtained from the Tokyo Medical Examiner's Office. We excluded 409 cases for the following reasons: criminal death, injury-related death, suicide, intoxication, non-sudden death, not bathtub-related death, out-of-bathroom death, subject aged under 65 years, undetermined bathing date, institutional housing, and bathing not at subject's home. Ultimately, 999 cases were analyzed. Daily mean temperature data were collected. A time-series regression study was performed to estimate the influence of sex, age, and bathing day temperature. Monthly changes in the population bathing in a bathtub were considered in the model. RESULTS: The relative risk (RR) of sudden unexpected death in a bathtub was 1.381 for males (95% confidence interval [CI]: 1.218-1.564) compared to females. The RRs were 4.182 (95% CI: 3.523-4.986) and 9.382 (95% CI: 7.836-11.273) among those aged 75-84 years and ≥85 years, respectively, compared to among those aged 65-74 years. The RR increased to 1.092 (95% CI: 1.082-1.102) as the daily mean temperature decreased by 1 °C. CONCLUSION: Sudden unexpected death in a bathtub correlated with bathing day temperature among elderly Japanese adults, and extremely low temperature, male sex, and older age increased the risk of such death. Our findings provide insight into preventing sudden unexpected deaths in bathtubs.

Epidemiology of Alcohol-related Death while Bathing in a Bathtub.

OBJECTIVES: Alcohol consumption before bathing is listed as a risk factor for sudden death in a bathtub, which occurs relatively frequently in Japan. This study aimed to clarify the epidemiology of alcohol-related deaths in bathtubs. SUBJECTS: Among all autopsy cases that were performed at the Tokyo Medical Examiner's Office between 2009 and 2010 (N = 5635), 357 cases of death in a bathtub were evaluated. Data regarding age, sex, blood ethanol level, manner and. cause .of death, alcohol consumption, and alcohol-related gastrointestinal diseases were extracted. The cases were divided into three groups according to their blood ethanol levels (no blood ethanol, low ethanol, and high ethanol), and their data were compared. RESULTS: A large majority of the cases in all groups involved persons who were 50-89 years old. The mean age of the high ethanol group (61.7 years) was significantly lower than.that of the control group (71.1 years; P < 0.01). In addition, the proportion of men was significantly higher in the low and high ethanol groups (70.1% and 75.5%, respectively), compared to that in the control group (55.9%; P < 0.05). Daily alcohol consumption was significantly more common in the low and high ethanol groups (49.5% and 87.8%, respectively), compared to that in the control group (23.2%; P < 0.01). Furthermore, alcohol-related gastrointestinal diseases were more common in the low and high ethanol groups (26.8% and 63.3%, respectively), compared to that in the control group (4.3%; P < 0.01). CONCLUSIONS: Preventive strategies for reducing alcohol-related deaths in bathtubs should target male habitual drinkers (middle-aged to seniors), especially patients who have been diagnosed with alcohol-related diseases.

Bath-related deaths in Kagoshima, the southwest part of Japan.

In Japan, sudden death in the bathroom (what we call 'bath-related death') has been reported to occur particularly in the elderly population in the winter. This investigation aimed to obtain a better understanding of the factors associated with bath-related deaths. For this purpose, a retrospective review of the inquest records in Kagoshima Prefecture, the southwest part of Japan, during 2006-2007 was performed. There were 338 cases of bath-related death, which corresponds to a crude mortality rate of 9.7 per 100,000 persons per year. The occurrence of bath-related death was similar to that of other prefectures in Japan, despite the warm environment in Kagoshima. The victims' ages ranged from 37 to 101 years (mean 76.6 years) and 88.8% of patients were over 65 years. The associated factors included winter season (56.2%) and a medical history of hypertension (37.3%). These demographic and circumstantial factors correlated with previous studies in Japan. These results suggest that the Japanese method of bathing, in addition to cold bathrooms in winter, contributes to the high rate of bath-related death in Japan. In addition, the mortality rate of people who lived alone was significantly higher than that of those who lived with their families. Most cases occurred in the home bathroom (84.9%) at the time when elderly people usually bathe (48.7%). Our results indicate that bath-related death occurs most often during the normal daily life of the aged. Protective activities of the Japanese government and society should aim to reduce the number of these tragic deaths in the bathroom. Further, no autopsies were performed on the cases in this study. Therefore, the rate of autopsies in bath-related death should be increased in order to accumulate data based on objective evidence.

Reducing drowning deaths: the continued challenge of immersion fatalities in Australia.

OBJECTIVE: To explore 5 years of drowning deaths in Australia compared with a previous Australian study a decade earlier, and to assess the feasibility of achieving a 50% reduction in unintentional drowning deaths by 2020. DESIGN AND SETTING: An audit of all unintentional drowning deaths in Australia using data from the National Coroners Information System for 1 July 2002 to 30 June 2007. MAIN OUTCOME MEASURES: Number and rate of drowning deaths, by age, sex, location, activity, place of birth, visitor status, and involvement of alcohol or drugs. RESULTS: There were 1452 drowning deaths during the study period (76.4% male). The age-adjusted rate per 100 000 people ranged from 1.61 in 2002-03 to 1.23 in 2006-07. Children aged 0-4 years had the highest rate (2.63 per 100 000 people), and 29% of deaths were of people aged 55 years or older. Over half of all deaths occurred in rivers (20.3%), at beaches (18.3%), or in swimming pools (13.3%). Alcohol was involved in 21.6% of all drowning deaths, although this varied by age. CONCLUSIONS: This audit suggests that a 50% reduction in drowning fatalities by 2020 may be achievable using current knowledge and preventive systems in certain types of immersions. However, further research and new initiatives will be required, particularly to prevent drowning deaths in rivers and of older people.

The role of bath seats in unintentional infant bathtub drowning deaths.

OBJECTIVE: The objective of this study was to quantify and characterize the role of bath seats in infant mortality from bathtub drowning. METHOD: Risk analysis of bathtub drowning deaths for infants aged 6-10 months was performed using data available from the US Consumer Product Safety Commission (CPSC), birth and mortality data from the National Center for Health Statistics (NCHS) for US resident infants from 1990-1998, and bath seat ownership from the American Baby Group and industry sales data compiled by NPD to estimate bath seat use. The analysis computes the relative risks of infant drowning based on estimates of bath seat use with a cohort design and explores the potential confounding by a range of factors. RESULTS: In-depth analysis of the unintentional bathtub drowning deaths of American infants aged 6-10 months for the years 1994 through 1998 revealed 40 infant drowning deaths associated with bath seats and 78 deaths not associated with bath seats. Based on available data on sales and use that suggest approximately 45% of infants in this age group use bath seats, the existing data do not support a hypothesis that bath seats increase the risk of bathtub drowning for infants. Bath seats are not intended or marketed as safety devices, and analysis of the existing, albeit limited, data suggests that they either have no effect or they may provide some slight unexplained protection against unintentional bathtub drowning risks (with an odds ratio for the risk of drowning with a bath seat vs without a bath seat of approximately 0.6 [95% confidence interval (CI) 0.4-0.9]). Although all potential confounders cannot be fully explored due to incomplete data and large uncertainties remain, this analysis suggests that the US CPSC made the appropriate decision not to ban bath seats in response to petitions it received in 1994 and 2001. CONCLUSIONS: Increasing market sales and surveys of reported bath seat use were associated with decreasing unintentional infant bathtub drowning risks. Rigorous risk analyses should be conducted when considering regulating products to ensure that regulation does not inadvertently increase injury risks. Analysis of the factors associated with these deaths suggests that additional efforts are needed to ensure that caregivers do not leave infants unattended in the bathtub and to collect data that will further improve our understanding and management of these risks.

Effects of hot bath immersion on autonomic activity and hemodynamics: comparison of the elderly patient and the healthy young.

Hot bathing has been associated with sudden death and so the present study investigated its effects on autonomic activity and hemodynamics in the elderly patient and the healthy young by analyzing heart rate variability (HRV). Subjects were 9 elderly men (mean age, 75 years) and 9 young men (mean age, 27 years), who were immersed up to shoulder level while in a sitting position for 10min with the bath temperature at 40 degrees C. Blood pressure (BP) and heart rate (HR) were monitored. BP in the young decreased during bathing (p<0.01), whereas in the elderly BP had a maximum value just at the start of immersion (p<0.05) with a slight decline at 4 min after the start of immersion. Although HR in the young increased (p<0.01), in the elderly there was an abrupt increase in HR just at the start of immersion (p<0.05), followed by a decrease in HR. With regard to HRV, the high-frequency (HF) component in the young men was suppressed during immersion (p<0.01), but was unaffected in the elderly. The LF (low frequency)/HF ratio in the elderly decreased at 4 min (p<0.05). In conclusion, hypotensive syncope may cause sudden death by drowning during hot bathing, and is a consequence of the decrease in sympathetic tone that develops approximately 4min after immersion.

Shared bathing and drowning in infants and young children.

OBJECTIVE: A study was undertaken to look at possible risks of shared bathing in early childhood. METHODS: Autopsy databases were searched at the Women's and Children's Hospital and State Coroner's Office, Adelaide, Australia, from January 1963 to December 1999, the Victorian Institute of Forensic Medicine, Melbourne, Australia, from January 1991 to December 1999, and the Children's Hospital-San Diego, San Diego, USA, from January 1990 to December 1999, for all cases registered as drowning in children aged 2 years and under who were in a bath with another child around the time of death. RESULTS: A total of 17 cases were found. The age range of the victims was 8-22 months (average=11.8 months), with a male to female ratio of 10:7. The surviving children (who were all siblings) were significantly older, with an age range of 19-48 months (average=30.4 months), and a male to female ratio of 12:5. (The survivors were on average 18.5 months older than the victims, range=11-32 months). In every case the children had been left unsupervised for variable periods of time. CONCLUSIONS: These cases represented a significant component -- between 22 and 58% -- of bath drownings in the 2 years and under age group. It would appear that shared bathing for young children and infants may only acceptable if adult supervision is constant, and that a young sibling is not an appropriate person to look after an infant or toddler in the bath. While the risk of leaving an infant in a filled bath may be exacerbated if an older child is also present, further population-based studies are required to examine this hypothesis.

[Epidemiological analysis of deaths occurring while taking a bath].

An epidemiological analysis of deaths occurring while taking a bath was carried out in Tochigi Prefecture. Data concerning the numbers of deaths were obtained from the Tochigi Central Police Office. Long-term assessments from 1978 to 1992 were completed for a total number of 1,348 persons (793 men and 555 women). The annual number of deaths during taking a bath increased gradually from 43 in 1978 to 140 in 1992. Death occurred 1.43 times more frequently in males than in females. The number during summer was only one eighth that of the winter peak. In addition, the increase in mortality was proportional to age. The mortality figures per 100,000 were, 10 for 40-49 age group, 31 for 50-59, 79 for 60-69, 251 for 70-79 and 469 for those 80 and over. It is concluded that the number of deaths occurring while taking a bath has increased gradually in those 80 or over.