21 | Submersion Injuries with Dr Sarah Lazarus

21 | Submersion Injuries with Dr. Sarah Lazarus

In this episode of PEM CHATT, host Toni Dobson is joined by pediatric emergency physician Dr. Sarah Lazarus to break down the critical topic of pediatric drowning and submersion injuries. Together, they explore real-world clinical scenarios, debunk common myths, and provide practical guidance for both clinicians and caregivers.

Drowning remains one of the leading causes of death in children, particularly ages 1–4, and even non-fatal events can result in devastating long-term consequences. This episode emphasizes both clinical management and prevention strategies—highlighting how quickly these events occur and how often they happen despite close supervision.

🔑 Key Takeaways

• Drowning is fast and silent
  • Often occurs in seconds with little to no splashing or noise
• Terminology matters
  • “Dry drowning” and “secondary drowning” are outdated and misleading
• Pathophysiology is respiratory
  • Water aspiration → surfactant washout → impaired gas exchange → hypoxia
• Observation is critical
  • True aspiration events should be monitored for ~6 hours from the time of incident
• Imaging isn’t always helpful
  • Chest X-rays can lead to unnecessary admissions without changing outcomes
• Management is symptom-driven
  • Asymptomatic → observe
  • Symptomatic → oxygen support, VBG, imaging, admission
• Cardiac arrest cases are severe
  • Focus on oxygenation, ventilation, rewarming, and consider ECMO early
• Prevention requires layers
  • No single strategy (including swim lessons) is sufficient

⚠️ Clinical Pearls

• Drowning is an evolving process, not a single moment event
• Patients should be observed for 6 hours after the event
• Symptoms appearing days later are NOT due to drowning
• Pediatric arrests are often respiratory in origin → prioritize ventilation
• Antibiotics and steroids are not routinely indicated
• Most toddler submersion injuries do NOT require C-spine immobilization

🧠 Myth Busting

“Dry drowning” isn’t real. This term originated from outdated medical concepts but is no longer used. If a child had a true submersion injury, symptoms will present within 6 hours—not days later.

🛟 Prevention Insights

• Use “arms reach, eyes reach” supervision
• Perform a home swim test (can the child swim 2 pool lengths?)
• Understand that:
  • Swim lessons ≠ drowning proof
  • Life jackets ≠ guaranteed safety
• Drowning prevention requires multiple overlapping layers of safety

Resources and references:

• Brenner’s article: https://pubmed.ncbi.nlm.nih.gov/19255386/
• CHOA Algorithm: https://www.choa.org/-/media/Files/Childrens/medical-professionals/clinical-practice-guidelines/submersion-event-ed.pdf
• NEJM Article: https://www.nejm.org/doi/full/10.1056/NEJMra1013317#figures_media

Timeline

00:00 Welcome to PEM CHATT

00:19 Why Drowning Matters

01:12 Meet Dr. Sarah Lazarus

02:14 Bread Pudding is my favorite

03:34 Drowning Terminology

04:38 Who Is Most at Risk

06:08 Silent Drowning Explained

09:15 Systemic Effects Checklist

11:03 Fresh vs Salt vs Cold

11:46 Three Patient Categories

12:36 Case One Asymptomatic Kid

14:12 Avoiding Unneeded X-Rays

16:12 Case Two Symptomatic Infant

18:40 Imaging and Labs Strategy

18:58 When to Skip Antibiotics

20:02 Arrest Scenario Walkthrough

20:30 Resuscitation Priorities And ECMO

21:54 When Resuscitation Is Futile

22:40 C-Spine Immobilization Debate

23:24 Drowning CPR Starts with Breaths

25:29 Injury Prevention Work and Stats

27:14 Layers of Drowning Prevention

30:01 Dry Drowning Myth Busting

33:16 Key Pearls and Closing