Exposure/Environment A complete physical examination requires removal of all clothing, log rolling, and checking axillary and perineal areas of the patient Hypothermia is a particular risk in ill and injured children, due to their larger relative surface area Hypothermia can develop in the prehospital setting and can worsen in the ED, as proper assessment and treatment requires exposure of the patient The dangers of hypothermia include impaired hemodynamics and coagulation, increased peripheral vascular resistance, and increased metabolic demand Monitor and maintain body temperature using increased ambient temperature, warm blankets, and warmed fluids and oxygen While the use of therapeutic hypothermia in arrested pediatric patients remains understudied, hyperthermia should be treated aggressively IV Access Vascular access is an early but often challenging necessity in resuscitation Percutaneous cannulation of bilateral upper extremity veins with two large-bore intravenous (IV) cannulas is ideal For patients in pulseless arrest, for those with severe trauma, or for patients with known difficult access, intraossesous (IO) access provides a quick, reliable route to provide fluid resuscitation and medications ED clinicians should have an IV escalation plan in place with resources to assure timely IV access This has become a more important aspect of care due to the increasing numbers of children with difficult IV access due to success in treating chronic illnesses ( Table 7.6 ) Fluid Resuscitation Deliver isotonic fluids (normal saline or lactated Ringer’s) rapidly in 20 mL per kg aliquots up to 60 mL/kg and reassess VS, MS, and skin perfusion The push–pull technique using a 20-mL syringe with a macrodrip setup with a three-way stopcock and a T-connector is useful for rapid fluid resuscitation in children 50 kg, fluids can be infused using a pressure bag or a rapid infuser To date, evidence has not shown benefit for the use of albumin or synthetic colloids in pediatric septic shock, cardiopulmonary arrest, or trauma Dextrose-containing solutions should not be used for initial resuscitation due to risk for hyperglycemia and secondary osmotic diuresis and neurologic injury Nevertheless, bedside glucose testing is important; treat hypoglycemia with 10% dextrose solution, and follow with an infusion of dextrose-containing fluids in persistently hypoglycemic patients If volume resuscitation of 60 mL/kg has not been effective, consider initiating procontractility agents or vasopressors Treat hypoxemia, metabolic acidosis, and any other critical electrolyte abnormalities discovered during the resuscitation Among traumatically injured patients, failure to respond to crystalloid resuscitation is an indication for early transfusion Blood transfusion is preferentially performed