Epidemiological analysis of intramuscular hemorrhage of respiratory and accessory respiratory muscles in fatal drowning cases.

The postmortem diagnosis of drowning death and understanding the mechanisms leading to drowning require a comprehensive judgment based on numerous morphological findings in order to determine the pathogenesis and epidemiological characteristics of the findings. Effortful breathing during the drowning process can result in intramuscular hemorrhage in respiratory and accessory respiratory muscles. However, the characteristics of this phenomenon have not been investigated. We analyzed the epidemiological characteristics of 145 cases diagnosed as drowning, in which hemorrhage, not due to trauma, was found in the respiratory muscles and accessory respiratory muscles. Hemorrhage was observed in 31.7% of these cases, and the incidence did not differ by gender or drowning location. The frequency of hemorrhage was significantly higher in months with a mean temperature below 20°C than in months above 20°C, suggesting a relationship between the occurrence of hemorrhage and low environmental temperature. Moreover, the frequency of hemorrhage was significantly higher in the elderly (aged ≥65 years) compared to those <65 years old. In the elderly, the weakening of muscles due to aging may contribute to the susceptibility for intramuscular hemorrhage. Moreover, these intramuscular hemorrhages do not need to be considered in cases of a potential bleeding tendency due to disease such as cirrhosis or medication such as anticoagulants. Our results indicate that intramuscular hemorrhage in respiratory and accessory respiratory muscles can serve as an additional criterion to differentiate between fatal drowning and other causes of death, as long as no cutaneous or subcutaneous hematomas above the muscles with hemorrhages are observed. In addition, the epidemiological features that such intramuscular hemorrhage is more common in cold environments and in the elderly may provide useful information for the differentiation.

Treatment of the lung injury of drowning: a systematic review.

BACKGROUND: Drowning is a cause of significant global mortality. The mechanism of injury involves inhalation of water, lung injury and hypoxia. This systematic review addressed the following question: In drowning patients with lung injury, what is the evidence from primary studies regarding treatment strategies and subsequent patient outcomes? METHODS: The search strategy utilised PRISMA guidelines. Databases searched were MEDLINE, EMBASE, CINAHL, Web of Science and SCOPUS. There were no restrictions on publication date or age of participants. Quality of evidence was evaluated using GRADE methodology. RESULTS: Forty-one papers were included. The quality of evidence was very low. Seventeen papers addressed the lung injury of drowning in their research question and 24 had less specific research questions, however included relevant outcome data. There were 21 studies regarding extra-corporeal life support, 14 papers covering the theme of ventilation strategies, 14 addressed antibiotic use, seven papers addressed steroid use and five studies investigating diuretic use. There were no clinical trials. One retrospective comparison of therapeutic strategies was found. There was insufficient evidence to make recommendations as to best practice when supplemental oxygen alone is insufficient. Mechanical ventilation is associated with barotrauma in drowning patients, but the evidence predates the practice of lung protective ventilation. There was insufficient evidence to make recommendations regarding adjuvant therapies. CONCLUSIONS: Treating the lung injury of drowning has a limited evidentiary basis. There is an urgent need for comparative studies of therapeutic strategies in drowning.

Immunohistochemical renal expression of aquaporin 2, arginine-vasopressin, vasopressin receptor 2, and renin in saltwater drowning and freshwater drowning.

The diagnosis of drowning is considered one of the most difficult in forensic medicine. Due to the paucity of signs, it is a classical diagnosis by exclusion. For this reason, specific immunohistochemical markers would be useful. Far too little has been done to analyze in-depth the differences between SWD and FWD. We focused on the renal immunohistochemical expression of aquaporin 2, AVP, V2R, and renin in cases of drowning. This study has two purposes: (1) to better understand the differences between saltwater drowning (SWD) and freshwater drowning (FWD), which may indicate different pathophysiology and (2) to eventually identify markers useful for the diagnosis of drowning. We retrospectively investigated 10 cases of SWD gathered from the Institute of Legal Medicine in Genoa (Italy), and 10 cases of FWD from the University Center of Legal Medicine in Geneva (Switzerland). As a control group, we investigated 10 cases of death by gunshot to the head. A strong expression of AQP2 and AVP was significantly (p < 0.05) more evident in cases of SWD than in FWD and control cases. Regarding the V2R, no statistically significant differences were found between the studied groups. The renin tubular expression was particularly intense (p < 0.05) both in SWD and in FWD compared controls. According to our results, AQP2 and AVP represent potential useful markers for the differential diagnosis between SWD and other causes of death, including FWD. Renin may be a useful marker in the diagnosis of drowning but it does not allow for differentiation between FWD and SWD.

Swimming is compromised in Parkinson's disease patients.

BACKGROUND: A recent survey reported a high risk of drowning in Parkinson's disease (PD) patients. This study intended to assess PD patients' swimming ability and explore the disease-related characteristics that may affect this. METHODS: A cross-sectional study was conducted in idiopathic PD patients. The assessment included swimming in 2 different styles and the evaluation of isolated technical gestures. The primary outcome was the frequency of patients who were able to swim. Limb coordination, blockage episodes, and capacity to maintain the body in a horizontal position were also evaluated. RESULTS: Thirteen patients were evaluated. Three patients were able to swim according to the predefined definition. The inability to maintain the horizontal position and floatability were the main reasons identified for the decrease in swimming performance. CONCLUSIONS: Swimming ability is compromised in some PD patients. Further studies are needed to evaluate the global frequency of swimming difficulties in PD patients and their contributing factors. © 2019 International Parkinson and Movement Disorder Society.

El ahogamiento: epidemiología, prevención, fisiopatología, reanimación de la víctima ahogada y tratamiento hospitalario / Drowning: epidemiology, prevention, pathophysiology, resuscitation, and hospital treatment

El objetivo de esta revisión narrativa fue elaborar un documento que trate los aspectos clave del ahogamiento de acuerdo con la evidencia científica disponible. El ahogamiento se define como el proceso de sufrir dificultades respiratorias por sumersión/inmersión en un líquido. El tiempo de sumersión es un factor clave en la supervivencia y daño neurológico. Aunque el distrés respiratorio e hipoxia es el cuadro predominante, pueden presentarse otras complicaciones que afecten a distintos sistemas y aparatos. El ahogamiento es una de las principales causas de muerte accidental en el mundo. Sin embargo, la mortalidad por ahogamiento está infraestimada y la morbilidad desconocida. La prevención es el factor clave para la reducción de la mortalidad y morbilidad, pero si esta falla, la rapidez y calidad del tratamiento tanto prehospitalario como hospitalario determinarán el pronóstico. Por tanto, resulta fundamental conocer los factores y mecanismos particulares implicados en esta emergencia

This narrative review discusses the evidence relevant to key aspects of drowning, which is defined by the World Health Organization as the process of respiratory difficulty caused by submersion/immersion in liquid. The length of time the victim is submerged is a key factor in survival and neurologic damage. Although respiratory distress and hypoxia are the main events, other complications affecting various systems and organs may develop. Drowning is one of the main causes of accidental death worldwide, yet deaths from drowning are underestimated and morbidity is unknown. Prevention is essential for reducing both mortality and morbidity, but if prevention fails, the speed of access to and the quality of prehospital and hospital care will determine the prognosis. It is therefore essential to understand the factors and mechanisms involved in these emergencies

Drowning: epidemiology, prevention, pathophysiology, resuscitation, and hospital treatment. / El ahogamiento: epidemiología, prevención, fisiopatología, reanimación de la víctima ahogada y tratamiento hospitalario.

This narrative review discusses the evidence relevant to key aspects of drowning, which is defined by the World Health Organization as the process of respiratory difficulty caused by submersion/immersion in liquid. The length of time the victim is submerged is a key factor in survival and neurologic damage. Although respiratory distress and hypoxia are the main events, other complications affecting various systems and organs may develop. Drowning is one of the main causes of accidental death worldwide, yet deaths from drowning are underestimated and morbidity is unknown. Prevention is essential for reducing both mortality and morbidity, but if prevention fails, the speed of access to and the quality of prehospital and hospital care will determine the prognosis. It is therefore essential to understand the factors and mechanisms involved in these emergencies.

El objetivo de esta revisión narrativa fue elaborar un documento que trate los aspectos clave del ahogamiento deacuerdo con la evidencia científica disponible. El ahogamiento se define como el proceso de sufrir dificultades respiratorias por sumersión/inmersión en un líquido. El tiempo de sumersión es un factor clave en la supervivencia y dañoneurológico. Aunque el distrés respiratorio e hipoxia es el cuadro predominante, pueden presentarse otras complicaciones que afecten a distintos sistemas y aparatos. El ahogamiento es una de las principales causas de muerte accidental en el mundo. Sin embargo, la mortalidad por ahogamiento está infraestimada y la morbilidad desconocida. Laprevención es el factor clave para la reducción de la mortalidad y morbilidad, pero si esta falla, la rapidez y calidaddel tratamiento tanto prehospitalario como hospitalario determinarán el pronóstico. Por tanto, resulta fundamentalconocer los factores y mecanismos particulares implicados en esta emergencia.

Long-Term Survival After Drowning-Related Cardiac Arrest.

BACKGROUND: Long-term outcomes after drowning-related cardiac arrest are not well characterized. OBJECTIVE: Our aims were to estimate long-term survival and identify prognostic factors in a large, population-based cohort of drowning victims with cardiac arrest. METHODS: We conducted a population-based prospective cohort study (1974-1996) of Western Washington Drowning Registry (WWDR) subjects with out-of-hospital cardiac arrest and attempted professional resuscitation. The primary outcome was long-term survival through 2012. We tabulated Utstein-style exposure variables, estimated Kaplan-Meier curves, and identified prognostic factors with Cox proportional hazard modeling. RESULTS: Of 2824 WWDR cases, 407 subjects (median age 17 years [interquartile range 3-33 years], 81% were male) were included. Only 54 (13%) were still alive after 1663 person-years of follow-up. Most deaths occurred after termination of initial resuscitation or during initial hospitalization. Risk of subsequent death after hospital discharge was 9.6 (95% confidence interval [CI] 5.7-15.9) per 1000 person-years. Long-term survival differed by Utstein variables (older age, illicit substance use, pre-drowning activity, submersion duration, cardiopulmonary resuscitation duration, intubation, defibrillation, and medications) and inpatient markers of illness severity (vital signs, Glasgow Coma Scale, laboratory values, shock). In adjusted analyses, older age (hazard ratio [HR] 1.01; 95% CI 1.01-1.02), epinephrine administration (HR 1.92; 95% CI 1.31-2.80), antiepileptic administration (HR 0.53; 95% CI 0.35-0.81), initial arterial pH (HR 0.49; 95% CI 0.26-0.92), and shock (HR 2.19; 95% CI 1.16-4.15) were associated with higher risk of death. CONCLUSIONS: Most cases of drowning-related cardiac arrest were fatal, but survivors to hospital discharge had a low risk of subsequent death that was independently associated with older age and clinical evidence of shock.

Cold Water Immersion Syndrome and Whitewater Recreation Fatalities.

Sudden death during whitewater recreation often occurs through understandable mechanisms such as underwater entrapment or trauma, but poorly defined events are common, particularly in colder water. These uncharacterized tragedies are frequently called flush drownings by whitewater enthusiasts. We believe the condition referred to as cold water immersion syndrome may be responsible for some of these deaths. Given this assumption, the physiologic alterations contributing to cold water immersion syndrome are reviewed with an emphasis on those factors pertinent to flush drowning.

Immunohistochemical expression of P-selectin, SP-A, HSP70, aquaporin 5, and fibronectin in saltwater drowning and freshwater drowning.

The diagnosis of drowning is one of the most difficult in forensic medicine. The aim of this study was to analyze pulmonary tissue reactions in death by drowning. In particular, we focused on the immunohistochemical expression of P-selectin, SP-A, HSP70, AQP-5, and fibronectin to investigate our expression in drowning and to understand whether there are differences between saltwater drowning (SWD) and freshwater drowning (FWD), which may indicate a different pathophysiology. We retrospectively investigated 10 cases of SWD (Mediterranean Sea) from the Institute of Legal Medicine of Genoa (Italy), and 10 cases of FWD (Lake of Geneva) from the University Center of Legal Medicine of Geneva (Switzerland). As control group, we examined 10 cases of death by acute external bleeding, characterized by minimal respiratory distress. As compared with controls, in SWD cases, the results showed a decrease of SP-A expression with membrane patterns. Furthermore, we observed a greater SP-A expression with granular pattern in drowning cases without statistically significant difference between SWD and FWD. For the markers AQP-5, HSP70, fibronectin, and P-selectin, no statistically significant differences were found between SWD, FWD, and controls.

Clinical characteristics of elderly drowning patients.

PURPOSE: Drowning is one of the major causes of traumatic death. The impact of drowning in the elderly and patients who were not elderly will be different because of physiological differences. We wanted to analyze the clinical differences such as mortality, incidence rate of complications, degree of hypothermia and rate of cardiac arrest between elderly and adult drowning patients. METHODS: This study included drowning patients over 18 years old who came to an emergency department (ED) located on a riverside from September 1997 to July 2016. Patients over the age of 65 years were classified as elderly, while those under the age of 65 years were classified as adults. Demographic data and clinical outcomes were surveyed. RESULTS: A total of 611 patients were included in this study. Sixty-one patients (9.9%) were elderly, and 550 patients (90.1%) were adults. There were 17 elderly patients (15.8%) and 87 adult patients (27.9%) who had cardiac arrest at the time of ED arrival (p = 0.017). The rate of body temperatures < 34 °C was higher in elderly patients than that in adult patients (27.9% vs 17.5%, respectively, p = 0.025). The rates of hospitalization in the intensive care unit (ICU) and mortality were higher in elderly group (23% vs. 15.1%, respectively, p = 0.01; 37.7% vs 21.8%, respectively, p = 0.01). There was no significant difference in suicidal intent between the elderly and adult patient groups (82.0% vs 78.9%, respectively, p = 0.421). CONCLUSIONS: Elderly drowning patients accounted for approximately 1/10 of all drowning cases and were more likely to experience a cardiac arrest, hypothermia, mortality, and ICU admission.

Drowning in fresh or salt water: respective influence on respiratory function in a matched cohort study.

INTRODUCTION: For the most severe drowned patients, hypoxemia represents one of the major symptoms. As the influence of the type of water (fresh or salt water) on respiratory function is still unclear, the primary endpoint of this multicenter study was to compare hypoxemia according to the type of water. METHODS: Medical records of adult patients who experienced a drowning event and were consequently admitted to 10 ICU for acute respiratory failure were analyzed retrospectively using data collected over three consecutive summer periods. From an initial cohort of acute respiratory failure drowned patients, patients were matched by age, sex, Glasgow Coma Scale, and occurrence of cardiac arrest (yes or no). RESULTS: Among an initial cohort of 242 patients, 38 pairs were matched correctly. At the initial assessment, carried out upon ICU admission, hypoxemia was found to be deeper in the fresh water group (PaO2/FiO2: 141 ± 76 vs. 220 ± 122, P < 0.05). However, there was no significant difference in tissue oxygenation (assessed by blood lactate level) between groups. In terms of biology results, sodium levels were higher in the salt water group in the initial assessment (144 ± 6.8 vs. 140 ±5.2 mmol/l, P = 0.004), but no difference was observed later. No difference was recorded in the outcome or length of stay in ICU between groups. CONCLUSION: Drowning in fresh water was associated with deeper hypoxemia in the initial assessment. Despite this initial difference, latter respiratory and biological parameters or outcome were similar in both groups.

A new look at survival times during cold water immersion.

This paper presents an expanded dataset for survival times during cold water immersion. In 1946, the first set of human data for cold water survival was derived from the US Navy medical reports during WWII. Although this is the largest and most widely used data source, it has only 23 data points and immersion times are less than 5.5 h for water temperature below 20 °C. For the new dataset, data (i.e., immersion times, water temperatures, clothing worn, and in some cases, body masses, heights, and survival times for the deaths witnessed by survivors) was retrieved from 12 well-documented incidents of accidental immersions which involved 22 survivors and 21 deaths. These data were combined with the 1946 dataset to create the expanded dataset which included 122 data points. Analysis of the dataset revealed critical details pertinent to cold water survival: 1) immersion times, up to 75 h, at water temperatures below 20 °C, were longer than most immersion times documented in the 1946 dataset; 2) thermal protection (wetsuit or drysuit), high body mass, and partial immersion may significantly impact survival during immersion in cold water; 3) twenty-one actual survival times until witnessed death are added. A maximal survival time curve was derived to represent the survival limit which many victims are unlikely to approach and few can exceed except under unique circumstances.

Drowning Management.

Highly skilled swimmers and aquatically adaptable service members such as U.S. Navy Divers, Sea, Air and Land (SEAL) Teams, and Explosive Ordnance Disposal (EOD) technicians, die every year from drowning. Drowning is the cause of over 500,000 deaths annually across the globe. This Clinical Practice Guideline (CPG) provides an overview of drowning and associated conditions based on the best available current medical evidence. Unlike basic life support and advanced cardiac life support protocols, rescue breathing should be initiated prior to chest compressions to re-expand water-filled alveoli. These guidelines should be used as a standardized framework to guide first responders, prehospital emergency medical service personnel, and medical department personnel in evaluating, diagnosing, and managing common in water pathologies.

Submersion injuries in the United States: Patients characteristics and predictors of mortality and morbidity.

INTRODUCTION: Drowning leads to 372,000 deaths annually worldwide and to severe morbidity secondary to asphyxiation or aspiration. Previous studies described submersion injuries mainly in the pediatric population. This study describes characteristics of patients presenting with submersion injuries to United States emergency departments (EDs) and identifies predictors of poor outcomes (death or long term neurologic deficits) after drowning. METHODS: This retrospective cross-sectional study included ED visits for submersion injuries from the United States 2013 Nationwide Emergency Department Sample (NEDS) dataset using discharge data (CCS diagnosis codes). Descriptive analysis was done for the collected variables and was followed by a multivariate regression analysis to identify predictors of poor outcomes (mortality and morbidity). RESULTS: A total of 12,529 weighted patients presented to EDs for submersion injury in 2013 yielding a rate of 9.29 per 100,000 ED visits. Patients were more frequently males (65.8%, 95%CI: 64.0-67.6) and in the 19-65 years age group (41.8%, 95%CI: 40.0-43.6). Poor outcomes were present in 11.7% (95%CI: 10.5-13.0) of patients. Significant positive predictors of poor outcomes were: male gender (OR = 1.761, 95%CI: 1.247-2.487); presence of chronic conditions involving infectious and parasitic disease (OR = 2.824, 95%CI: 1.155-6.908), the circulatory system (OR = 12.818, 95%CI: 8.953-18.351), the respiratory system (OR = 1.498, 95%CI: 1.079-2.079) or the digestive system (OR = 2.006, 95%CI: 1.106-3.636); associated motor vehicle traffic injury (OR = 5.221, 95%CI: 1.563-17.441) and self-payers. CONCLUSION: Submersion remains a high impact emergency condition in the United States. Significant predictors of poor outcomes were identified. Prevention efforts targeting susceptible population are needed to reduce the impact of submersion injuries on different communities in the United States.

Functional integrity in children with anoxic brain injury from drowning.

Drowning is a leading cause of accidental injury and death in young children. Anoxic brain injury (ABI) is a common consequence of drowning and can cause severe neurological morbidity in survivors. Assessment of functional status and prognostication in drowning victims can be extremely challenging, both acutely and chronically. Structural neuroimaging modalities (CT and MRI) have been of limited clinical value. Here, we tested the utility of resting-state functional MRI (rs-fMRI) for assessing brain functional integrity in this population. Eleven children with chronic, spastic quadriplegia due to drowning-induced ABI were investigated. All were comatose immediately after the injury and gradually regained consciousness, but with varying ability to communicate their cognitive state. Eleven neurotypical children matched for age and gender formed the control group. Resting-state fMRI and co-registered T1-weighted anatomical MRI were acquired at night during drug-aided sleep. Network integrity was quantified by independent components analysis (ICA), at both group- and per-subject levels. Functional-status assessments based on in-home observations were provided by families and caregivers. Motor ICNs were grossly compromised in ABI patients both group-wise and individually, concordant with their prominent motor deficits. Striking preservations of perceptual and cognitive ICNs were observed, and the degree of network preservation correlated (ρ = 0.74) with the per-subject functional status assessments. Collectively, our findings indicate that rs-fMRI has promise for assessing brain functional integrity in ABI and, potentially, in other disorders. Furthermore, our observations suggest that the severe motor deficits observed in this population can mask relatively intact perceptual and cognitive capabilities. Hum Brain Mapp 38:4813-4831, 2017. © 2017 Wiley Periodicals, Inc.

Cold water immersion: kill or cure?

NEW FINDINGS: What is the topic of this review? This is the first review to look across the broad field of 'cold water immersion' and to determine the threats and benefits associated with it as both a hazard and a treatment. What advances does it highlight? The level of evidence supporting each of the areas reviewed is assessed. Like other environmental constituents, such as pressure, heat and oxygen, cold water can be either good or bad, threat or treatment, depending on circumstance. Given the current increase in the popularly of open cold water swimming, it is timely to review the various human responses to cold water immersion (CWI) and consider the strength of the claims made for the effects of CWI. As a consequence, in this review we look at the history of CWI and examine CWI as a precursor to drowning, cardiac arrest and hypothermia. We also assess its role in prolonged survival underwater, extending exercise time in the heat and treating hyperthermic casualties. More recent uses, such as in the prevention of inflammation and treatment of inflammation-related conditions, are also considered. It is concluded that the evidence base for the different claims made for CWI are varied, and although in most instances there seems to be a credible rationale for the benefits or otherwise of CWI, in some instances the supporting data remain at the level of anecdotal speculation. Clear directions and requirements for future research are indicated by this review.

Therapeutic Hypothermia for Asphyxial Out-of-Hospital Cardiac Arrest Due to Drowning: A Systematic Review of Case Series and Case Reports.

The objective of this review was to summarize published evidence of the effectiveness of therapeutic hypothermia in patients with drowning-associated asphyxial out-of-hospital cardiac arrest (OHCA) and to explore any preliminary favorable factors in the management of therapeutic hypothermia to improve survival and neurological outcome. Drowning may result in asphyxial OHCA or hypothermic OHCA, but the former does not provide any potential neuroprotective effect as the latter may do. Electronic literature searches of Ovid Medline, Embase, Cochrane Library, and Scopus were performed for all years from inception to July 2016. Primary studies in the form of case reports, letters to the editor, and others with higher quality are included, but guidelines, reviews, editorials, textbook chapters, conference abstracts, and nonhuman studies are excluded. Non-English articles are excluded. Relevant studies are then deemed eligible if the drowning OHCA patient's initial temperature was above 28°C, which implies asphyxial cardiac arrest, and intentional therapeutic hypothermia was instituted. Because of the narrow scope of interest and strict definition of the condition, limited studies addressed it, and no randomized controlled trials (RCT) could be selected. Thirteen studies covering 35 patients are included. No quantitative synthesis, assessment of study quality, or assessment of bias was performed. It is conjectured that extended therapeutic hypothermia of 48-72 hours might help prevent reperfusion injury during the intermediate phase of postcardiac arrest care to benefit patients of drowning-associated asphyxial OHCA, but this finding only serves as preliminary observation for future research. No conclusive recommendation could be made regarding the duration of and the time of onset of therapeutic hypothermia. Future research should put effort on RCT, particularly the effect of extended duration of 48-72 hours. Important parameters should be reported in detail. Asphyxial and hypothermic OHCA should be differentiated.

Acute respiratory failure after drowning: a retrospective multicenter survey.

OBJECTIVES: Despite the extensive literature on drowning, clinical data are still lacking on the best medical strategy to use. Acute respiratory failure (ARF) is the main component of drowning pathophysiology. The objectives of this multicenter study were to analyze the clinical course of drowning-related ARF patients and to describe the efficacy of the ventilatory strategies used. METHODS: Medical records of drowned adult patients admitted in seven ICUs after prehospital emergency medical care during three consecutive summer periods were retrospectively analyzed. RESULTS: Among the 126 patients (58±21 years) admitted, 38 patients with cardiac arrest at the scene were not analyzed, 26 received mechanical ventilation (MV), and 48 patients received noninvasive ventilation (NIV). Compared with patients placed under MV, the NIV patients presented a better initial neurological (Glasgow Coma Scale of 7±4 vs. 12±3, P<0.05) and hemodynamic status from the prehospital stage (mean arterial pressure of 77±18 vs. 96±18, P<0.001). With comparable ARF-related hypoxemia to MV, the NIV was maintained with success in 92% (44/48). Both MV and NIV were associated with rapid improvement of oxygenation and short ICU length of stay [3 (1-14) and 2 (1-7), respectively]. CONCLUSION: Despite the absence of recommendation for NIV use in case of drowning-related ARF, this technique was often used with safety and efficacy. The decision for NIV use was mainly based on the preserved or improved neurological status.

Quenching tank: Accidental drowning in hot quenching oil.

We describe an unusual case of drowning in fluid other than water in an industrial setting. A 26-year-old man was working in an industry which performs surface treatment of mechanical steel parts with quenching oil. He fell into the quenching oil (which was hot due to immersion of red hot metal parts), and as he was working alone in the particular section, there was a fatal outcome. A medico-legal autopsy was performed. The causes of death were found to be multiple, with the association of drowning, extensive superficial burns and asphyxia due to laryngeal oedema. To our knowledge, it is the first report of drowning in hot quenching oil, and only nine previous observations of drowning in industrial environments have been reported in the international literature. Even though rare, these kinds of accidental deaths can be prevented in dangerous industries with proper precautions and strict adherence to standard operating procedures.