Underwater

death,Dysbarism,Scuba
death,Social Autopsy.
Underwater death,Dysbarism,Scuba death,Social Autopsy.

DYSBARISM:
Dysbarism consists of those disturbances in the body exclusive of hypoxia
and air sickness that result from existence of a pressure differential
between the total ambient barometric pressure and the total pressure of
dissolved and free gases within the body tissues, fluids and cavities.

Classification of Dysbarism

Dysbarism has been classified by Adler as:

1.Those due to hyperbarism:
Result from an excess gas pressure over that with in the body fluids,
tissues and cavities are noted during the descent.
2.Hypobaric effects:
Result from excess of gass pressure with in the body fluids, tissues and
cavities over ambient gas pressure, are noted during ascent.

Injuries From Hyperbarism (Barotrauma)

Physical effects related to increase in atmospheric pressure are referred to

as barotraumas. It occurs most frequently under water.
The pressure of underwater environment is always greater than that of
atmosphere.
When pressure of air or gas in body cavity differs from surrounding tissues,
problems of dysbarism arises. The failure to maintain equality of pressure
between body and surroundings may be due to the:
(i) Weakness of the individual himself (ii) Inadequacy of the protection
available to him or his equipment (iii)Mishandling of the equipment by other
people.
When an individual inhales a lungful of air and plunges in to aquatic
environment, as he descends in to water, chest pressure increases with
increasing depth and the volume of air in lungs is decreased as air
pressure increases.
At about 100 ft, the total respiratory volume may be reduced to residual
volume and with increasing descent air in the lungs is at constant volume

X
Roman Al Mamun
DR. 2|Page
Underwater death,Dysbarism,Scuba death,Social Autopsy.

and pressure but pressure of pulmonary circulation and tissue wall

continues to increase.
Thus a pressure difference is created resulting in pulmonary oedema by
fluid transfer from the alveolar capillaries into alveolar spaces leading to
vessel rupture and haemorrhage, the air pressure increases than that of
tissues that results in pulmonary tissue rupture and air escapes into
interstitial tissue or pleural cavity or be drawn into circulation.
High altitude decompression sickness has symptoms similar to those of
Caisson disease but the two differs in circumstances of development and
progression of the process.

Syndromes of Barotraumas

Pulmonary Barotraumas
This can manifest as pneumothorax, interstitial emphysema and air
embolism causing chest and abdominal pain, nose bleeding,
haemoptysis,coughing and cyanosis.
Immediate recompression is mandatory to shrink the embolism bubble
mass.
The clinical effects of air embolism depend upon the actual site namely,
convulsions, visual changes, spastic/ flaccid paralysis, tingling in the limbs
and vertigo.

Barotalgia
The second location where injury from barotraumas can occur is in middle
ear where air pressure differs from that in the external ear and
nasopharynx.

If air pressure in middle ear cannot be kept in equilibrium with that of

nasopharynx for example because of inflammation of Eustachian tube,
eardrum may bulge inwards resulting in stretching, pain, haemorrhage, and
ultimately perforations.

This occurs in sudden descents from high places such as mountains or in

landing of an aircraft, and in diving. In diving this is more of a problem but

X
Roman Al Mamun
DR. 3|Page
Underwater death,Dysbarism,Scuba death,Social Autopsy.

acute pain prevents diver to go deep enough to produce the perforation in

his ear.
If an individual is wearing a tight fitting cap, air may be trapped in external
canal.

Barosinusitis and Barodontalgia

Divers experience vertigo or dizziness under water and those with sinusitis
or polyps of nasopharynx may experience a painful condition owing to
pressure variations between surrounding tissue and sinuses.
Small pockets of gas resulting from fermentation in the roots of teeth may
shrink during compression and the space becomes occupied by blood or
fluid with increased pressure and pain when the diver returns to the
surface.

Intestinal Complications:
As a result of increased volume of gaseous content of intestinal tract,
continued fermentation may produce additional gas which will cause
abdominal distension, discomfort and embarrassing flatulence upon return
to the surface.

Nitrogen Narcosis and Oxygen Poisoning:

Despite the chemically unreactive nature of some noble gases at certain
pressures they display all typical properties of anesthetic agents.
Nitrogen makes up about 79% of the air we breathe, produces euphoria
followed by narcosis.
With alcohol, the effect of nitrogen is greatly enhanced.
Usually upon release of pressure,excess nitrogen leaves tissues and
recovery is complete.
Helium is used in place of nitrogen in breathing mixtures which allows for
deeper diving potentials.

Hyperemia (Oxygen poisoning)

The effects may result from prolonged exposure to low oxygen
concentration or brief exposure to very high tensions (1500 mmHg).

X
Roman Al Mamun
DR. 4|Page
Underwater death,Dysbarism,Scuba death,Social Autopsy.

Acute oxygen poisoning is much more common danger in diving.

Convulsions are reported if divers have breathed pure oxygen at a
pressure of 4 atm.
At depths greater than 25 ft pure oxygen is not currently used.
Mechanism of oxygen poisoning includes an excessively high partial
pressure of oxygen.
In chronic oxygen poisoning, irritant effect on lung tissue from smaller
excess pressure for a considerable time may be there.

SCUBA Diving Fatalities

SCUBA is a Self Contained Underwater Breathing Apparatus.

The diver is supplied by one or more tanks strapped to his back, which
enable him to remain submerged for indefinite periods of time Snorkeling:
The hazards are similar to that of swimming.
It refers to diving appratus that has mouth piece at one end and the other
end of the tube remains above the surface of water unless the diver
submerges, when the spherical float attached to it keeps the water from
entering it.

The diver holds his breath for the length of time he remains underwater.
These fatalities are contributed by four basic groups of factors:

1. Panic in minor emergencies such as: (i) Loss of a mouth piece or face
mask (ii)Entrapment in kelp or gill net (iii) Poor judgment in estimating
distance from safety.
2. Improper use or maintenance of equipment:
(i) Insufficient servicing (ii) Use of defective components (iii) Occasionally
regulators are defective (iv) Water may be inhaled instead of air.
3. Acute alcoholism: Due to alcoholism, judgments are impaired and
inhibitions are lost.
4. Organic diseases: Cardiovascular diseases especially severe coronary
sclerosis.

X
Roman Al Mamun
DR. 5|Page
Underwater death,Dysbarism,Scuba death,Social Autopsy.

Hypoxia is associated with increased susceptibility to the effects of alcohol,

impairment of coordination of muscular activity and decreased perception
of depth and colour.

Hazards of Scuba diving :

include drowning,barotraumas, bends (Caisson’s disease), acute
pulmonary oedema, emphysema, pneumothorax and air embolism.

In Scuba diving, frequently there is entrapment of air with in the lungs on

rising from depths producing fatal or non-fatal extraalveolar air syndrome.
Air escapes from alveoli and may result in interstitial
emphysema,pneumothorax and air embolism.

It is caused by disproportionate expansion of air containing alveoli

compared to the adjacent fluid filled vascular changes during too rapid an
ascent.

Water Accident Investigation Team (WAIT)

The medicolegal investigation technique for water accidents is developed
by Noguchi.

It consists of forensic pathologist and his medical or paramedicalsupport

team, diving expert (may be a medical officer who has sufficient
experience in hyper baric medicine).

The work of this team is coordinated by means of a liaison officer.

Every scuba fatality should be thoroughly documented and investigated as
to what happened, circumstances surrounding the death and what
recommendations should be made to prevent such incidents.

The training should be improved and licensing and maintenance of diving

gear is important to prevent such fatalities.
A coordinated effort should be made with active sports diving equipment
manufacturers.

X
Roman Al Mamun
DR. 6|Page
Underwater death,Dysbarism,Scuba death,Social Autopsy.

Medicolegal Autopsy in Fatal Water Accidents

including Scuba Deaths:
1. Do not remove any mask or gear from the divers, as equipment should
be examined for flaws such as absence of a weight belt.
2. Photograph the tank and send it to proper testing facility.
3. Leave wetsuit undisturbed until the autopsy begins.
4. Document the time of notification, arrival time and diving time.
5. Conversations with witnesses such as skipper, other divers and diving
instructions are important.
6. Photograph the body in position in which it was found underwater (face
down, face up) as soon as possible.
7. Note the condition of the body especially rigor mortis.
8. There should be minimum disturbance of the position of the remains,
diving gear, wetsuit and safety equipments.
9. Transfer the body to the examining room without delay to prevent
artefacts being increased by putrefaction.

External examination:
The external examination should be conducted from top of head to tips of
toe without missing any surface of skin as:
1. Evidence of squeezing or pressure of skin.
2. Eyelid, conjunctiva, sclera, neck and thoracic wall should be examined
for subcutaneous emphysema.
3. Radiological examination: X-ray of chest in standing position will indicate
a fluid level in chest cavity or presence of pneumothorax or
pneumomediastinum. Radiographs of knees will show nitrogen bubbles in
the joint, indicating a long diving period.
4. In case of air embolism, air samples should be removed with a syringe
lubricated by oil for gas chromatography and electron mass spectrometer
analysis of gas components. >95% nitrogen indicates nitrogen narcosis (In
case of massive air embolism from rupture of lungs, O2 to N2 ratio would
be 20 : 80%).

X
Roman Al Mamun
DR. 7|Page
Underwater death,Dysbarism,Scuba death,Social Autopsy.

• While giving skin incisions, never overlook small air bubbles coming out
from subcutaneous tissue.
• Blood is generally fluid, not coagulated.
• Heart need not be opened underwater.
• It is more important to measure total amount of air in heart chambers to
find out air embolism.

5. Stomach contents must be examined for presence of food, drugs or

alcohol.

Injuries Relating to Low Atmospheric Pressure

(Hypobarism)
The barometric or atmospheric pressure at sea level is above 760 mm Hg.
This pressure is referred to as standard or 1atm if temperature is 0oC.
The effects of hypobarism are related to its causation by:
(i) Evolved gas types (ii) Trapped gas types.

Evolved Gas Types

Gases are evolved and form bubbles when with a rapid decrease in
ambient pressure, tissues saturated with a dissolved gas may become
supersaturated.

Nitrogen is implicated in most of the cases but oxygen and carbon dioxide
may also form and cause dysbarism.
In the bodynnitrogen is transported in simple solution according to Henry’s
law.
It enters into and is removed from the body by establishment of equilibrium
between nitrogen pressure in the alveolar air and venous blood and
another between tissues and arterial blood.

During an ascent, ambient nitrogen pressure is decreased and nitrogen

transport is directed towards its removal from the lungs.
Nitrogen in tissue, then being higher in pressure than that of arterial blood,
is transported to blood then to alveolar air and is expired.

X
Roman Al Mamun
DR. 8|Page
Underwater death,Dysbarism,Scuba death,Social Autopsy.

As only a small amount of nitrogen can be transported by a given amount

of blood, the rapid reduction in ambient pressure results in super saturation
of the tissues with the resultant bubble formation.
Nitrogen bubbles can form in any tissue including blood and are
characterized by bends and chokes.

Bends are joint pains caused by evolved gas bubbles with in the joints and

Chokes are characterized by cough, chest pain and dyspnoea due to

pulmonary evolved gas as well as mediastinal emphysema from evolved
gas bubbles.
CNS symptoms are caused by evolved gas pressure on or in the brain as
well as embolic phenomenon. CNS disturbances are produced due to
evolved gas bubbles under the skin.
Microcirculatory phenomenon are produced due to bubble pressure on
nerves and blood vessels.

Trapped Gas Types

Gases may be trapped in hollow viscera, teeth or body cavities with
resultant pain and possibility of ruptures.
Gases may be trapped in sinuses, middle ear, teeth, joints, beneath skin,
and intestinal tract.

Factor Effecting Clinical Manifestations of

Hypobarism

1. Age.
2. Obesity: Fatty tissue contains less blood than muscular tissues and
nitrogen is five times as soluble in fat as in muscle.
3. Exercise, because of concomitant increase of tissue metabolic carbon
dioxide.
4. Rate of ascent.
5. Attained altitude during ascent.
6. Increased tissue pressure of nitrogen prior to ascent.
7. Recent scuba diving:

X
Roman Al Mamun
DR. 9|Page
Underwater death,Dysbarism,Scuba death,Social Autopsy.

8. Lower ambient temperature: Occurs with great frequency because of

decreased nitrogen transport associated with peripheral vasoconstriction
due to cold.
9. Total dissolved gas tension.
10. Previous injury: Bubbles tend to form at the sites of recent injuries
11. Repeated exposure: Having one such attack of dysbarism is prone to
another episode.

Clinical Features
1.The Bends: Onset follows the ascent with a variable lag period. It
includes joint symptoms, joint pain muscles, long bones. The areas
involved are first the knee then shoulder, elbow, wrist, hand and finger in
decreasing order. The features are not serious and may be relieved in
descent
2. The Chokes: Are characterized by substantial distress, nonproductive
cough, respiratory distress, sense of apprehension and suffocation.
The chokes are more serious than the bends.

They result from bubble formation and accumulation in the pulmonary

capillaries or from the effects of extravascular mediastinal bubbles exerting
pressures on mediastinal contents and adjacent pulmonary tissue.
It may be solitary manifestation of hypobarism and may accompany the
bends.
Chokes are found later than bends in the flight and become progressively
disabling.
Cough and substantial distress are markedly aggravated when an attempt
is made to take deep breath resulting in decreased pulmonary ventilation,
then hypoxia, syncope and collapse.

Onset of chokes demands: (i) Prompt attention (ii) Return to normal

pressure by way of descent to lower altitude (iii) Termination of flight of
aircraft (iv) Removal from low pressure chambers.

X
Roman Al Mamun
DR. 10 | P a g e
Underwater death,Dysbarism,Scuba death,Social Autopsy.

3. CNS involvement: Vision is disturbed and there is disturbance in

orientation.
This is related to bubble size and location of lodging in the arterioles and
capillaries of the brain, indicate mandatory hospitalization.
4. Skin manifestation: Are due to pressure on dermal nerve endings
and sub dermal emphysema revealed by crepitation on palpation.
5. Rapid and explosive decompression: They result from mechanical
failure of aircraft pressurization system.
6. Explosive decompression: Loss of pressure is less than a second in
explosive decompression and more than a second in rapid decompression.
The eardrums are ruptured in the absence of basal skull fractures.
Microscopic examination of lungs will reveal presence of bone marrow
emboli resulting from nonfatal injuries sustained before ground impact.

SOCIAL AUTOPSY:
SOCIAL AUTOPSY:

A social autopsy is an in-depth investigation of a

multitude of psychosocial circumstances surrounding
deaths occurring in a particular group of people.

Increased use of social autopsy is needed to improve

maternal, neonatal and child health programmes in low-
income countries.(WHO)

In essence, the social autopsy methodology is used to

examine the contribution of social, personal, health,
and environmental variables to unusual mortality rates.

The data needed to estimate cause-specific mortality

X
Roman Al Mamun
DR. 11 | P a g e
Underwater death,Dysbarism,Scuba death,Social Autopsy.

rates can be obtained through verbal autopsy, which

consists of the use of standardized interview tools to
question the caretakers of recently deceased persons
about the symptoms that preceded the death.

While verbal autopsy data can be used to prioritize

health problems and evaluate health programme impact,
social autopsy data, which focus on modifiable factors
present in the home, community and health system, can
inform policies and practices for increasing access to
and use of preventive and curative services.

Despite its importance, social autopsy has not been

widely practiced and still lacks standard methods for
data collection and analysis.

Two key models,known as Pathway to Survival and Three

Delays, have been used to organize the care-seeking
data generated by social autopsy.

The pathway identifies and organizes modifiable social,

cultural, and health system factors affecting home care
practices, health care access and utilization, and the
delivery of quality health care Pathway to Survival
Three Delays to formal health care seeking and related
constraints:

1. Lack of knowledge of illness danger signs

2. Seeking traditional care
3. Lack of transportation,costs.

X
Roman Al Mamun
DR. 12 | P a g e
Underwater death,Dysbarism,Scuba death,Social Autopsy.

The five key objectives of social autopsy are as

follows:

(i) Essential elements of the care-seeking process to

be described, including recognition of the illness,
home care provided, outside-the-home care was sought
(informal, formal, or both), delays to formal health
care seeking and related constraints and the quality of
health care provided.
(ii) A social diagnosis of the contributors to death
to be made, i.e., household (behavioural), community
(social), and health system determinants of the deaths
to be identified.
(iii) The study should provide representative national
or large area data; and the data should be utilized to
support.
(iv) Health program or policy development
and/or
(v) Community empowerment.

X
Roman Al Mamun
DR. 13 | P a g e