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  • “Dry drowning” and “secondary drowning” are outdated and misleading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 This term originated from outdated medical concepts but is no longer used.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

In this “Rewind” episode, Toni sits down with retired pediatrician Dr. Margaret “Meg” Wang, who trained and practiced through the pre-vaccine and early-vaccine eras of pediatrics, including the 1989–1990 measles epidemic in New York City. Together, they walk us through what pediatrics looked like before Hib, pneumococcal, varicella, and rotavirus vaccines and what we might face again as vaccination rates fall and herd immunity wanes.

You’ll hear vivid, frontline stories of:

• Hib meningitis, occult bacteremia, and epiglottitis in infants and toddlers, when full sepsis workups (blood, urine, CSF, IV antibiotics, 72-hr admissions) were standard for many febrile children through 36 months of age.
• “Old-school” periorbital and buccal cellulitis from Hib—bright red with a violaceous hue, toxic kids, high fevers, and automatic LP + admission.
• Measles in an actual epidemic: the prodrome with the “three Cs” (cough, coryza, conjunctivitis), Koplik spots, and that classic confluent, head-to-toe rash, plus why measles is not a mild illness.
• Varicella beyond the “nuisance rash”: super-itchy multi-stage lesions, serious skin infections, and a child who developed Staph aureus bacteremia and tricuspid valve endocarditis requiring open-heart surgery—all from chickenpox in an unvaccinated child.
• Rotavirus winters: the green, watery, diaper-filling diarrhea, relentless fluid losses, metabolic acidosis, hypoglycemia in infants, and frequent admissions—versus the near-disappearance of severe rotavirus disease after the vaccine.

Clinically, Toni and Dr. Wang dig into:

• How fever protocols for 0–36 month-olds have evolved from routine full sepsis workups to today’s more nuanced approach with viral testing and inflammatory markers like CRP and procalcitonin.
• Bedside pattern recognition for epiglottitis (toxic, drooling, tripod positioning, chin thrust, neck extension) and why you never upset these kids or put a tongue blade in their mouth—just get them upright and straight to controlled intubation with anesthesia.
• The role of parental gut instinct and why “this is not my kid” should always make you pause and reassess.

🔑 Key Takeaways:

• Vaccines didn’t just reduce visit volumes; they completely changed inpatient and ED workflows, procedure rates (LPs!), and long-term morbidity (e.g., deafness after meningitis).
• As coverage declines, we won’t just see “more fevers”—we’ll see sicker kids, more invasive procedures, more admissions, and more preventable complications.
• Your vaccine counseling today is part of preventing tomorrow’s “Rewind” from becoming reality again.

📌 Call to Action:

Hit play, then share this episode with a colleague, resident, or trainee who has never seen these diseases and thinks of measles or chickenpox as “mild.” Their future patients are counting on it. 💉🧠

Fever Management in Children 3-36 Months: An Evidence-Based Approach

Join host Toni Dobson and guest Andrea Perkins, PA-C, as they dive deep into the evidence-based management of fever in otherwise healthy children aged 3-36 months. This comprehensive episode covers everything from basic fever physiology to algorithmic approaches for both vaccinated and unvaccinated children.

Key Topics Covered:

Defining fever and understanding the pathophysiology

The critical difference between fever and hyperthermia

Vaccination status and risk stratification

Comprehensive physical exam pearls

Evidence-based algorithms for immunized vs. unimmunized children

UTI risk assessment and when to obtain urine samples

Laboratory workup guidelines based on vaccination status

Fever management strategies and parent education

Addressing fever phobia in families

Resources:

UTI Calculator: www.uticalc.com

UpToDate management guidelines: UpToDate Link

Andrea's algorithm: Link to Algorithm

Next Episode: Dr. Margaret Wang joins us to discuss the return of vaccine-preventable illnesses and how we can prepare.

📺YouTube: https://www.youtube.com/@PEMChatt

🟢Spotify: https://open.spotify.com/show/6oaYDeq5AXIZGxBvEIxaTs

🍎 Apple Podcasts: https://podcasts.apple.com/us/podcast/pem-chatt/id1806882767