Accidental drowning: an unusual case [CJRM

Accidental drowning: an unusual case

Mark G. Robson, MD, CCFP

CJRM 2000;5(3):139-40.

As a rural coroner I am occasionally called to assess a person who has drowned. While driving to the site, the investigator must consider various modalities of death. Commonly, drowning is associated with drugs, alcohol or hypothermia, and the ability to swim. As well, drownings occur secondary to accidents, such as head and neck injuries associated with diving or body surfing.^1,2 Less commonly in our culture, the person could have died before being placed into the water.³ The following is an unusual case report of "accidental drowning."

History

On a midsummer's day in 1998, the Ontario Provincial Police (OPP) called to say they had found a missing swimmer who had apparently drowned at a local lake the previous day.⁴ An 18-year-old youth, a visitor to the area, had been jumping with friends off a 7-m rock into deep water. The mechanism of jumping was feet first while trying to turn 360° in a vertical axis. The man did come up after a second jump, established visual contact with others and was seen to be at the edge of the lake about to climb up for another jump. About 10 minutes later, he was noted to be missing from the group. An immediate search of the area was conducted with negative results. The following morning the OPP dive team found the youth in deep water, 6.5 m from the rock face.

The preliminary autopsy revealed features typical of freshwater drowning. There were no external injuries and no alcohol or drugs noted in the blood. As coroner I was faced with explaining to his distraught parents that their son, who was known to be a competent swimmer, had somehow drowned.

I spoke with the pathologist on several occasions regarding the possibility of neck injuries, as I had received a verbal report of a similar death elsewhere in Ontario. Despite the lack of anatomical evidence of neck injury, the case was referred to a neuropathologist for further examination. Over the winter I had 2 further conversations with family members, who were still not coping well with their son's supposed drowning.

In March 1999, the final autopsy included the following diagnoses: (1) mild hypoxic encephalopathy, (2) microscopic epidural and subdural hematomas and (3) petechial hemorrhages in the upper cervical spinal cord (C5) (Drs. L. Eidus and V. Montpetit, Department of Anatomic Pathology, Ottawa Hospital, General Campus, Ottawa: autopsy report, 1999). These findings were consistent with a spinal cord contusion resulting in drowning.

Again, the family was notified and was greatly relieved, despite the agonizing time frame, to learn that some discrete mechanism could now explain their son's death.

Discussion

Before receiving the final autopsy report, this case had weighed heavily on my mind. I wondered just how simple it was for a person to drown, given the lack of any of the usual precipitating factors. Our hospital librarian ran a MEDLINE search of drownings related to rock jumping and diving. Virtually all reports related either to head entry into shallow water or to body surfing injuries resulting in hyperflexion of the cervical spine.

Thanks to the direction of Dr. Charles H. Tator (Professor and Chairman, Division of Neurosurgery, University of Toronto and President, Think First Foundation of Canada: personal communication, 1999) my research subsequently led me to the SCIWORA syndrome (spinal cord injury without radiographic abnormality).⁵ Pang and Wilberger coined this term in 1982 for children with neurologic injury in the absence of demonstrable fracture or dislocation.⁶ The syndrome was postulated to be due to nondisruptive and self-reducing intersegmental deformation of the excessively malleable juvenile spine. Most of the originally described cases had flexion and extension forces applied to their necks from violent injuries. Most of these injuries were related to motor vehicle trauma, allowing them the benefit of acute care assessment and treatment.

Spinal cord injuries that occur during water recreation and sport activities are the fourth leading cause of spinal cord injury, and nearly 66% of these are related to diving.⁷ This case report is unusual in that the mechanism of injury is unknown. One is left to theorize that the manner in which he jumped into the water (i.e., vertical twisting and possibly jerking forward as his feet entered the water) caused a transient subluxation of the cervical spine resulting in a concussion of the cord at C5.

As a consequence of this neck injury I suspect that he had a period of apnea or loss of consciousness at some point after one of his jumps and although his friends had seen him surface, he subsequently disappeared under the water.

By reporting this case I am promoting professional awareness of SCIWORA syndrome and public awareness that rock jumping should be well supervised for water depth and underwater obstacles to ensure the well-being of any participants.

Correspondence to: Dr. Mark G. Robson, 346 John St. N, Arnprior ON K7S 2P6

This article has been peer reviewed.

References

Ferguson J, Beattie TF. Occult spinal cord injury in traumatized children. Injury 1993;23(2 ):83-4.
Branche CM, Sniezek JE, Sattin RW. Water recreation-related spinal injuries: risk factors in natural bodies of water. Accid Anal Prev 1991;23(1)13-7.
Carter N, Green A, Green MA. Problems in the interpretation of hemorrhage into neck musculature in cases of drowning. Am J Forensic Med Pathol 1998;19(3):223-5.
Sudden death report. Toronto: Ontario Provincial Police, 1998. File no. 109546-3
Pang D, Pollack IF. Spinal cord injury without radiographic abnormality in children -- the SCIWORA syndrome. J Trauma 1989;29 (5):654-64.
Pang D, Wilberger J. Spinal cord injury without radiographic abnormality in children. J Neurosurg 1982;57:114-29.
DeVivo MJ, Sekar P. Prevention of spinal cord injuries that occur in swimming pools. Spinal Cord 1997;35:509-15.