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Gastric mucosal lacerations in drowning:

resuscitation artifact or sign of death by
drowning ("Sehrt's sign")?
Article in Forensic Science Medicine and Pathology January 2015
Impact Factor: 1.98 DOI: 10.1007/s12024-014-9641-9 Source: PubMed

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Claas Buschmann
Charit Universittsmedizin Berlin
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Forensic Sci Med Pathol

DOI 10.1007/s12024-014-9641-9

DIFFERENTIAL DIAGNOSIS

Gastric mucosal lacerations in drowning: resuscitation artifact

or sign of death by drowning (Sehrts sign)?
Claas T. Buschmann Simone Schmid
Michael Tsokos

Accepted: 25 November 2014

Springer Science+Business Media New York 2015

Case report
A 24-year-old man was stabbed in the chest with a knife.
Bystanders immediately carried out cardiopulmonary
resuscitation (CPR) with external cardiac massage and
artificial ventilation. Rescue personnel were called to the
scene, and paramedics and an emergency physician arrived
10 min later. CPR efforts continued for another 30 min but
were unsuccessful. The victim was pronounced dead at the
scene of the incident. Only a few hours later a medicolegal
autopsy was performed. Unfortunately, emergency medical
equipment had been removed from the body prior to
autopsy.
The autopsy of the deceased (body length 176 cm,
weight 69 kg) revealed sparse postmortem lividity. The
single stab wound to the chest had a skin defect of
1.3 9 2.7 cm with a depth of 16 cm into the right thoracic
cavity. Additionally the mucosa of the upper and lower oral
vestibule showed isolated and fresh hemorrhages measuring up to 0.3 9 0.4 cm. The oral mucosa itself was intact.
The stab wound corresponded to a smooth-edged lesion
in the lower lobe of the right lung with penetration of the
pericardium, the right ventricle, the interventricular septum, and the left anterior descending coronary artery
(LAD). The wound channel ended in the left ventricle.

C. T. Buschmann (&)
M. Tsokos

Institute of Legal Medicine and Forensic Sciences, University
Medical Centre Charite, University of Berlin, Turmstr. 21,
Building N, 10559 Berlin, Germany
e-mail: claas.buschmann@charite.de
URL: http://remed.charite.de
S. Schmid
State Institute of Forensic Medicine, Turmstr. 21, Building L,
10559 Berlin, Germany

There was 2,200 ml of blood present within the chest

cavity and 250 ml of blood inside the pericardium.
The most interesting observation was that the stomach
was overinflated but empty; in particular, no blood was
found within. In the cardiac region of the stomach, fresh
and isolated superficial radial tears of the gastric mucosa
with a maximum length of 4 cm were seen (Fig. 1). Neither peritoneal perforations of these tears nor hemorrhages
within the surrounding mucosa were apparent. The superficial mucosal tears occurred after cardiac arrest, as there
was no sign of existing circulation in their macroscopic
appearance. This observation bears some similarity to the
finding of Sehrts sign as occasionally described in
autopsy cases of drowning. These gastric alterations are
attributed to forceful CPR attempts; that is, artificial ventilation caused gastric stretching through over-inflation.
The toxicological analysis was negative, and cause of death
was determined to be hemorrhagic shock.

Discussion
First described in the 1930s by German forensic pathologists, radial superficial ruptures of the gastric mucosa may
occasionally be found in cases of drowning. According to
the German physician Ernst Theodor Sehrt, these mucosal
lesions may be a consequence of emesis of swallowed fluid
(Sehrts sign) [1, 2]. In fact, Sehrts sign is uncommon in drowning fatalities and it is not recognized as a
diagnostic finding in drowning cases described in the
English medicolegal literature. To our knowledge the only
available English reference to Sehrts sign is the recent
paper by Necas and Hejna [3]. In contrast, other autopsy
findings after unsuccessful CPR are well documented, such
as serial rib fractures due to external cardiac massage, or

123

Forensic Sci Med Pathol

Fig. 1 Fresh and isolated superficial radial tears of the gastric

mucosa with a maximum length of 4 cm in the cardiac region. No
peritoneal perforation, surrounding hemorrhages or bloody stomach
contents

retropharyngeal bleedings, tooth damage, and pharyngeal

mucosa lesions caused by multiple intubation attempts [4].
Unusual CPR artifacts may pose significant difficulties in
interpretation at autopsy but are not of less importance [5].
The association of gastric mucosal lacerations with CPR
has been reported since the 1960s [68]. As an increased
proportion of drowning victims have also undergone
unsuccessful CPR during the fatal event, it is important to
appreciate that the different causes of gastric mucosal
lacerations could complicate the determination of cause of
death.
In the case reported here, the radial tears of the gastric
mucosa clearly resulted from gastric over-inflation by air
administered during CPR including artificial ventilation.
This would be from either artificial respiration provided by
bystanders, or false (and then corrected) endotracheal
intubation by professional rescue personnel. False endotracheal intubation and other means of emergency airway
management, such as laryngeal tube insertion, were not
documented. Artificial respiration by bystanders seems a
more possible explanation for gastric over-inflation, particularly with regard to the oral vestibule mucosa hemorrhage, an injury which could be caused by mouth-to-mouth
and nose ventilation (kiss of life). We suggest that, in
this case, gastric tube insertion to relieve pressure during
CPR would have prevented the occurrence of gastric
overstretching [9].

123

Certain characteristics of tissue damage can indicate

whether blood circulation was functioning when the injury
was inflicted. In this case signs of blood circulation in the
radial mucosa tears were not macroscopically recognizable,
but histological examinations were not performed as there
was already a clear cause of death. In circumstances where
the cause of death is unrelated to drowning, it would not
usually be considered necessary to investigate these
observations any further. However, in cases of drowning
followed by unsuccessful CPR, macroscopic classification
of gastric mucosa findings at autopsy might not be easy and
would generally require further histological examination. It
is also necessary to determine whether drowning was the
cause of death, or whether the victim died prior to entering
the water. Sehrts sign as an indication of drowning as
the cause of death should be regarded with caution and be
considered very carefully in such circumstances. Furthermore, emergency medical equipment should remain with
the body prior to forensic examination to allow the forensic
pathologist to assess and interpret the effects of any medical procedures. The clinical and medicolegal relevance of
emergency medical measures must be recognized and
evaluated at the forensic autopsy, especially with regard to
the complications arising from the frequent occurrence of
CPR in such cases [9].

References
1. Sehrt E. Vorgang des Ertrinkens, seine Bekampfung und Verhutung. Munch Med Wschr. 1932;31:1229.
2. Sehrt E. Zur Frage des Ertrinkungstodes und seiner Bekampfung.
Munch Med Wschr. 1933;20:762.
3. Necas P, Hejna P. Eponyms in forensic pathology. Forensic Sci
Med Pathol. 2012;8:305401.
4. Buschmann C, Tsokos M. Frequent and rare complications of
resuscitation attempts. Intensive Care Med. 2009;35:397404.
5. Buschmann C, Schulz F. Delayed pericardial tamponade after
successful resuscitation. Resuscitation. 2009;80:13289.
6. Lundberg GD, Mattei IR, Davis CJ, Nelson DE. Hemorrhage from
gastroesophageal lacerations following closed-chest cardiac massage. JAMA. 1967;202:1236.
7. Anthony PP, Tattersfield AE. Gastric mucosal lacerations after
cardiac resuscitation. Br Heart J. 1969;31:725.
8. Demos NJ, Poticha SM. Gastric rupture occurring during external
cardiac resuscitation. Surgery. 1964;55:3646.
9. Buschmann C, Schulz T, Tsokos M, et al. Emergency medicine
techniques and the forensic autopsy. Forensic Sci Med Pathol.
2013;9:4867.