Forensic Science, Medicine and Pathology

, Volume 14, Issue 1, pp 18–25 | Cite as

Diagnosis of arterial gas embolism in SCUBA diving: modification suggestion of autopsy techniques and experience in eight cases

  • Josep M. Casadesús
  • Fernando Aguirre
  • Ana Carrera
  • Pere Boadas-Vaello
  • Maria T. Serrando
  • Francisco Reina
Original Article


The purpose of this study was to suggest modifications of autopsy techniques in order to improve post-mortem diagnosis of arterial gas embolism (AGE) based on multidisciplinary investigation of SCUBA diving fatalities. Five adult human cadavers from the voluntary donation program of the Human Anatomy Laboratory, and eight judicial autopsied bodies of SCUBA divers from the Forensic Pathology Service were assessed. Before performing any autopsies, we accessed the diving plan and the divers’ profiles for each case. We then introduced a new dissection procedure that included identification, isolation, and manipulation of carotid, vertebral and thoracic arterial systems. The dissected vascular structures that allowed optimall isolation of the systemic arterial circulation were identified and ligated. In three of the eight judicial cases, we had a strongly suggestive history of arterial gas embolism following pulmonary barotrauma (PBt/AGE). In these cases, the additional arterial dissection allowed us to clearly diagnose AGE in one of them. The autopsy of the rest of the cases showed other causes of death such as asphyxia by drowning and heart attack. In all cases we were able to reject decompression sickness, and in some of them we showed the presence of artefacts secondary to decomposition and resuscitation maneuvers. These results allow us to suggest a specific autopsy technique divided into four steps, aimed at confirming or excluding some evidence of dysbaric disorders according to a re-enactment of the incident. We have demonstrated the presence of large volumes of intravascular air, which is typical of PBt/AGE.


SCUBA-diving Autopsy Barotrauma, Arterial gas embolism 



We gratefully acknowledge the contribution of our colleagues and technical staff of the Institute of Legal Medicine and Forensic Sciences (A. Hospital, MD; FJ. San Miguel, MD; JM. Martínez-Calcerrada, and L. Cifuentes) for their help during autopsies, and the Anatomy Laboratory of Faculty of Medicine (J. San, MD, PhD and A. Puig, MD) for their help in the anatomic dissections. Gerard Carot-Sans, PhD, edited the final version of the manuscript.

Compliance with ethical standards

Conflict of interest


Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Institutional Research Committee and with the 1964 Helsinki Declaration and its later amendments, or comparable ethical standards.


  1. 1.
    Vann RD, Butler FK, Mitchell SJ, Moon RE. Decompression illness. Lancet. 2011;377:153–64.CrossRefPubMedGoogle Scholar
  2. 2.
    Lawrence C, Cooke C. Autopsy and the investigation of scuba diving fatalities. Diving Hyperb Med. 2006;36:2–8.Google Scholar
  3. 3.
    Edmonds C, Bennett M, Lippmann J, Mitchell S. Diving and subaquatic medicine. 5th ed. Boca Raton: CRC Press; 2016.Google Scholar
  4. 4.
    Robert G, Teather CV. Encyclopedia of underwater investigations. 2nd ed. Palm Beach Gardens: Best Publishing Company; 2013.Google Scholar
  5. 5.
    Lippman J, Baddeley A, Vann R, Walker D. An analysis of the causes of compressd-gas diving fatalities in Australia from 1972-2005. Undersea Hyperb Med. 2013;40:49–61.Google Scholar
  6. 6.
    Türkmen N, Akan O, Cetin S, Eren B, Gürses MS, Gündoğmuş UN. Scuba diver deaths due to air embolism: two case reports. Soud Lek. 2013;58:26–8.PubMedGoogle Scholar
  7. 7.
    Casadesús JM, Aguirre F. Estudio de las muertes durante la práctica de buceo. In: Delgado S, Bandrés F, Lucena J, editors. Tratado de Medicina Legal y Ciencias Forenses III. Patología y Biología. Forense. Barcelona: Bosch; 2011. p. 691–711.Google Scholar
  8. 8.
    Casadesús JM, Carrera A, San J, Puig A, Hospital A, San Miguel JF, et al. Embolism diagnosis in scuba diving: new autopsy guide porpouse. In: Pinart E, editor. I Abstract book of molecular biology, biomedicine and health. Girona: University of Girona; 2016. p. 44–5.Google Scholar
  9. 9.
    Denoble PJ, Caruso JL, Dear GL, Peiper CF, Vann RD. Common causes of open-circuit recreational diving fatalities. Undersea Hyperb Med. 2008;35:393–406.PubMedGoogle Scholar
  10. 10.
    Trytko BE, Bennett MH. Arterial gas embolism: a review of cases at Prince of Wales Hospital, Sydney, 1996 to 2006. Anaesth Intensive Care. 2008;36:60–4.PubMedGoogle Scholar
  11. 11.
    Desola J, Garcia L, Sala J. The combination of decompression sickness plus intrathoracic hyperpressive syndrome plus and near drowning: The diving Tragedy. In: Proceeding of the International Conference on Diving & Hyperbaric Medicine. A Joint Meeting of the EUBS and the ICHM. Barcelona; 2005. pp. 149–53.Google Scholar
  12. 12.
    Saukko P, Knight B. Dysbaric fatalities and barotrauma. In: Saukko P, Knight B, editors. Knight’s forensic pathology. 4th ed. Boca Raton, FL: CRC Press; 2015. p. 509–13.Google Scholar
  13. 13.
    Neumann TS, Jacoby I, Bove AA. Fatal pulmonary barotrauma due to obstruction of the central circulation with air. J Emeg Med. 1998;16:413–7.CrossRefGoogle Scholar
  14. 14.
    Clarke D, Gerard W, Norris T. Pulmonary barotrauma-induced cerebral arterial gas embolism with spontaneous recovery: commentary on the rationale for therapeutic compression. Aviat Space Environ Med. 2002;73:139–46.PubMedGoogle Scholar
  15. 15.
    Edmonds C, Bennett M, Lippmann J, Mitchell S. Investigations of diving fatalities. In: Edmonds C, Bennett M, Lippmann J, Mitchell S, editors. Diving and Subaquatic Medicine. 5th ed. Boca Raton: CRC Press; 2016. p. 583–600.Google Scholar
  16. 16.
    Edmons C, Caruso J. Recent modifications to the investigation of diving related deaths. Forensic Sci Med Pathol. 2014;10:83–90.CrossRefGoogle Scholar
  17. 17.
    Robert G, Teather CV. Scuba fatality-accident investigation. In: Robert G, Teather CV, editors. Encyclopedia of underwater investigations. 2nd ed. Palm Beach Gardens: Best Publishing Company; 2013. p. 303–77.Google Scholar
  18. 18.
    Plattner T, Thali MJ, Yen K, Sonnenschein M, Stoupis C, Vock P, et al. Virtopsy-post mortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI) in a fatal scuba diving incident. J Forensic Sci. 2003;48:1347–55.CrossRefPubMedGoogle Scholar
  19. 19.
    Cole AJ, Griffiths D, Lavender S, Summers P, Rich K. Relevance of postmortem radiology to the diagnosis of fatal cerebral gas embolism from compressed air diving. J Clin Pathol. 2006;59:489–91.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Wheen LC, Williams MP. Post-mortems in recreational scuba diver deaths: The utility of radiology. J Forensic Legal Med. 2009;16:273–6.CrossRefGoogle Scholar
  21. 21.
    Laurent PE, Coulange M, Bartoli C, et al. Appearance of gas collections after scuba diving death: a computed tomography study in a porcine model. Int J Legal Med. 2013;127:177–84.CrossRefPubMedGoogle Scholar
  22. 22.
    Busuttil A, Obafunka J. A review of the forensic investigation of scuba diving deaths. Sci Justice. 1995;35:87–95.CrossRefPubMedGoogle Scholar
  23. 23.
    Lawrence C, Cooke C. Autopsy and the investigation of scuba diving fatalities. The Royal College of Pathologists of Australasia: Melbourne; 2003.Google Scholar
  24. 24.
    Spitz WU. Selected procedures at autopsy. In: Spitz WU, Spitz DJ, editors. Spitz and Fisher’s medicolegal investigation of death: guidelines for the application of pathology to crime investigation. 4th ed. Springfield: Charles C Thomas·Publisher, LTD; 2006. p. 1243–74.Google Scholar
  25. 25.
    Caruso JL. Appendix F: Autopsy protocol for recreational scuba diving fatality. In: Vann RD, Lang MA, editors. Recreational diving fatalities workshop proceedings. Durham: Divers Alert Network; 2011. p. 277–9.Google Scholar
  26. 26.
    Caruso JL. Post mortem, how to. In: Denoble PJ, editor. Medical examination of diving fatalities symposium proceedings. Durham: Divers Alert Network; 2015. p. 34–41.Google Scholar
  27. 27.
    Murray AC, Rozen WM, Alonso-Burgos A, Ashton MW, Garcia-Tutor E, Whitaker IS. The anatomy and variations of the internal thoracic (internal mammary) artery and implications in autologous breast reconstruction: clinical anatomical study and literature review. Surg Radiol Anat. 2012;34:159–65.CrossRefPubMedGoogle Scholar
  28. 28.
    Casadesús JM, Bonastre MV, Crespo S, Martínez H, Martínez M, Subirana M, et al. Death in water. In: Castellà J, Marrón MT, Recio I, editors. Specific recommendations for the unification of judicial autopsies at the Institute of Legal Medicine of Catalonia. Barcelona: CEJFE, Generalitat de Catalunya; 2013. p. 63–7.Google Scholar
  29. 29.
    Oh ST, Kim W, Jeon HM, Kim JS, Kim KW, Yoo SJ, et al. Massive pneumoperitoneum after scuba diving. J Korean Med Sci. 2003;18:281–3.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Kot J, Sićko Z, Michałkiewicz M, Pikiel P. Pneumoperitoneum after diving-two clinical cases and literature review. Int Marit Health. 2005;56:135–45.PubMedGoogle Scholar
  31. 31.
    Bunni J, Bryson PJ, Higgs SM. Abdominal compartment syndrome caused by tension pneumoperitoneum in a scuba diver. Ann R Coll Surg Engl. 2012;94:237–9.CrossRefGoogle Scholar
  32. 32.
    Bernaldo de Quirós Y, González-Díaz O, Møllerløkken A, Brubakk AO, Hjelde A, Saavedra P, et al. Differentiation at autopsy between in vivo gas embolism and putrefaction using gas composition analysis. Int J Legal Med. 2013;127:437–45.CrossRefPubMedGoogle Scholar
  33. 33.
    Varlet V, Smith F, Giuliani N, Egger C, Rinaldi A, Dominguez A, et al. When gas analysis assists with postmortem imaging to diagnose causes of death. Forensic Sci Int. 2015;251:1–10.CrossRefPubMedGoogle Scholar
  34. 34.
    Bernaldo de Quirós Y, Saavedra P, Møllerløkken A, Brubakk AO, Jørgensen A, González-Díaz O, et al. Differentiation at necropsy between in vivo gas embolism and putrefaction using a gas score. Res Vet Sci. 2016;106:48–55.CrossRefPubMedGoogle Scholar
  35. 35.
    Varlet V, Dominguez A, Augsburger M, Lossois M, Egger C, Palmiere C, et al. Understanding scuba diving fatalities: carbon dioxide concentrations in intra-cardiac gas. Diving Hyperb Med. 2017;47:75–81.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Institute of Legal Medicine and Forensic Sciences of Catalonia, (Division of Girona, Spain)GironaSpain
  2. 2.Research Group on Clinical Anatomy, Embryology and Neuroscience (NEOMA), Department of Medical SciencesUniversity of GironaGironaSpain
  3. 3.Department of Medical Sciences, Faculty of MedicineUniversity of Girona (Spain)GironaSpain
  4. 4.Special Group for Underwater Activities (GEAS) of the Spanish Civil GuardEstartitSpain
  5. 5.ICS-IAS Girona Clinical LaboratorySaltSpain

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