Up to 20% of patients who suffer submersion injuries do not aspirate water. Patients who aspirate water into their lungs have washout of surfactant, resulting in diminished alveolar gas transfer, atelectasis, ventilation perfusion mismatch, and hypoxia. Noncardiogenic pulmonary edema results from moderate to severe aspiration. Physical examination findings at presentation vary. Lungs may be clear or have rales, rhonchi, or wheezes. Mental status ranges from normal to comatose. Patients are at risk for hypothermia even in “warm water” submersions.