signs of shock (poor end-organ perfusion) and treat with isotonic crystalloid boluses even if the blood pressure is normal The 2015 AHA Guidelines Update newly recommended caution in the use of fluid boluses for children with a severe febrile illness who are in settings with limited access to critical care resources, as they may be harmful Hypertonic saline causes an osmotic shift of fluid from the intracellular and interstitial spaces to the extracellular compartment, providing rapid volume expansion with less interstitial edema In addition, less volume is required allowing the bolus to be completed in a shorter period of time Hypertonic solutions are also believed to reduce ICP by establishing an osmotic gradient across the blood–brain barrier that draws water from the brain into the vascular space Conversely, potential detrimental effects include continued hemorrhage from injured blood vessels, and increased ICP due to leakage of sodium through a disrupted blood–brain barrier Currently, data does not support the use of hypertonic saline over isotonic crystalloid for the resuscitation of hypovolemic patients For hemorrhagic shock, current Advanced Trauma Life Support (ATLS) guidelines recommend considering “crystalloid-restrictive balanced blood product resuscitation” for patients with hemorrhagic injury, although current studies in pediatric patients are lacking at this time Application of this being a single 20mL/kg bolus, followed by a weight-based blood product administration Serum albumin concentration has been shown to be inversely related to mortality risk Thus, its use in the resuscitation of ill patients has been explored It is 30 times more expensive than crystalloid solutions and has limited availability Systematic reviews have failed to show benefit from its administration Albumin is believed to have some anticoagulant properties and may leak across the capillary wall, promoting edema DEFIBRILLATION AND CARDIOVERSION The true prevalence of VT and VF in children with cardiopulmonary arrest in published reports is approximately 10% in both IHA and OHCA pediatric arrest ( Table 9.7 ) An additional 10% to 15% will develop VT/VF as a subsequent rhythm Although the need for defibrillation is relatively uncommon, it must always be considered in arrest, especially in older children, children with a history of congenital heart disease or dysrhythmias, and children who experience a witnessed sudden collapse arrest Interestingly, a secondary analysis of the CARES registry found that though younger children (1 to years) with OHCA had a relatively low incidence of an initial shockable rhythm (11%) as expected, older children (9 to 18 years old) had an incidence of an initial shockable rhythm similar to that of adults (32%) TABLE 9.7 PRESENTING RHYTHM IN PEDIATRIC PATIENTS WITH OUT-OFHOSPITAL CARDIOPULMONARY ARREST AND IN-HOSPITAL CARDIOPULMONARY ARREST (%) Defibrillation is the asynchronous delivery of a shock to the myocardium in an attempt to produce simultaneous depolarization of a critical mass of myocardial cells to allow spontaneous repolarization and the resumption of a perfusing cardiac rhythm Most defibrillators deliver biphasic wave forms, allowing for successful defibrillation at a lower energy of 150 J Standard adult paddles, to 13 cm in diameter and pediatric paddles 4.5 cm in diameter, are available with most defibrillators The correct paddle size is that which makes complete uniform contact with the chest wall The large paddle can usually be used for infants older than year of age and/or weighing more than 10 kg Larger paddle surfaces result in decreased intrathoracic impedance and optimize the energy reaching the myocardium Electrode paste decreases impedance and prevents skin injury Paddles are applied anteriorly at the right upper chest below the clavicle and to the left of the nipple in the anterior axillary line directly over the heart; they are applied with pressure and should never touch each other Most defibrillators also have disposable hands-free adhesive pads that allow both rhythm recognition and shock delivery These can be applied in the same location on the arrested child, or anterior–posterior, immediately at the beginning of the resuscitation and aid in preventing delays in rhythm checks and treatment In addition, many defibrillators, when pads are placed anterior–posterior, can give feedback to the user on key CPR parameters, such as depth and rate of compressions, and adequacy of release The initial dose for defibrillation is J/kg, increased to J/kg if the first attempt is unsuccessful Automated external defibrillators (AEDs) automatically interpret the cardiac rhythm and, if pulseless VT/VF is present, advise the operator to deliver a charge They are small, easy to use, and have batteries that last for years For patients with pulseless VT/VF, early rapid defibrillation is the treatment of choice AEDs have been proven to be highly sensitive and specific when used on adults, and there is good evidence that its use in the out-of-hospital setting has resulted in a dramatic improvement in survival of adults with VF Pediatric-based ECG rhythm analysis algorithms for AEDs are 99% sensitive and specific for determining shockable and nonshockable pediatric rhythms Available AEDs deliver a standard adult charge between 150 and 200 J; they can be used for children >1 year of age An attenuating pediatric electrode system is available which decreases the charge delivered to 50 J and is preferred if available for children to year old For infants