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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,