| Abstract|| |
Aim: To survey the literature on Pediatric Emergency Medical Services (PEMS) with an aim to focus its drawbacks and emphasize the means of improvement. Materials and Methods: Published articles selected for inclusion were based on the significance and understanding of literature search on different aspects of PEMS. To meet this criterion, PubMed, PubMed Central, Science Direct, Uptodate, Med Line, comprehensive databases, Cochrane library and the Internet (Google, Yahoo) were thoroughly searched. Results: PEMS provide out-of-hospital medical care and/or transport the patients to definitive care. The task force represents specialties of ambulance transport, first aid, emergency medical care, life saving, trauma, emergency medicine, water rescue, and extrication. Preliminary care is undertaken to save the patients from different medical exigencies. The techniques and procedures of basic and advanced life-support are employed. A large number of weaknesses are recorded in PEMS system, such as ambulance transport irregularities, deficit equipment, lack of expertise, and ignorance of the pre-hospital care providers. These are discussed with special reference to a few examples of medical exigencies. Conclusions: The appointments in PEMS should be regularized with specific qualifications, experience, and expertise in different areas. Responsibility of PEMS should not be left to pre-hospital care providers, who are non clinicians and lack proper education and training. Pediatricians should be adequately trained to play an active role in PEMS. Meetings should be convened to discuss the lapses and means of improvement. Networks of co-operation between pre-hospital providers and experts in the emergency department should be established.
Keywords: Drawbacks, overview, pediatric emergency medical services
|How to cite this article:|
Al-Anazi AF. Pediatric emergency medical services and their drawbacks. J Emerg Trauma Shock 2012;5:220-7
| Introduction|| |
Children account for only a small percentage of pre-hospital emergencies, but are a special challenge to the out of hospital care providers, in view of extreme emotional stress and anxiety. They are not "small adults"; their anatomy and physiology (airway, breathing, circulation, muscle, and skeleton) deserve special consideration, since they grossly differ from an adult. The internal organs are in proximity to each other in children than in adults, and this places children at higher risk of traumatic injury.  The reactions and capabilities of children differ depending on their developmental stages (infants, 1-12 months; toddlers, 1-3 years; pre-school age, 4-5 years; school age, 6-12 years; adolescent, 13-18 years) and experiences in life.
Pediatric Emergency Medical Services (PEMS) are a type of emergency services that provide out-of-hospital acute medical care to different types of serious exigencies, such as life threatening allergic reactions, poisoning due to ingestion of drugs and chemicals, lethal venoms of snakes, accidents involving bones and skull fractures, brain injuries, respiratory failure, cardiopulmonary blockade, cardiac arrest, febrile seizures, drug overdose, burns and shocks and child abuse, in addition to transport of the patients to definitive care. , Literature reports suggest that the Emergency Medical Services (EMS) are designed to provide fast intervention for adult emergencies, whereas the specialized care that children require is often overlooked. In view of a paucity of literature on the subject and neglect of importance to child care in matter of emergency, it was found worthwhile to evaluate the drawbacks of PEMS, in order to focus attention for the required improvement.
| Materials and Methods|| |
Published articles selected for inclusion in this review were based on the significance, and understanding of literature search on different aspects of PEMS as compared to the EMS for adults. To meet this criterion, peer reviewed English language articles published up to June 2011 were selected from PubMed, PubMed Central, Science Direct, Up-to-date, Med Line, comprehensive databases, Cochrane library, and the Internet (Google, Yahoo). The search strategy combined terms that included the title and the keywords, with relevant deficiencies of PEMS as compared to Emergency Medical Services (EMS) for adults. Some older articles that were decisive in evolving the current understanding of the techniques, equipment used by PEMS and the different staff employed were difficult to be dispensed with; however, most of the references used are the articles published during last 10-15 years.
| Results|| |
The review constituted a systematic search of literature up to June 2011 on (1) pre-hospital medical exigencies, (2) groups of PEMS, (3) techniques involved in PEMS, (4) resources and equipment, (5) teams of PEMS, (6) role of pediatricians, (7) drawbacks of PEMS, (8) common drawbacks confronting medical exigencies, and (9) conclusion on how best PEMS be improved.
Pre-hospital medical exigencies
Anaphylactic shock is a life-threatening allergic reaction with cardiovascular collapse. This may occur either suddenly or may be preceded by pruritus, wheezing, dyspnea, urticaria, pallor, digestive symptoms, and weakness. Food allergens, injected drugs, and hymenoptera stings are the main etiologies. Anaphylactic shock requires an emergency treatment and the PEMS team should be thoroughly prepared for any eventuality. Wheezing is a serious allergic reaction. In infants and older children, wheezing is due to bronchiolitis.  Wheeze, associated with asthma is often prone to allergic reactions; death can result due to anaphylaxis, if not treated instantly. 
Poisoning in children of all age groups is a significant health problem. Most of the paramedic transport calls are reported for accidental poisonings in patients of age group 5 years and younger. Among the different groups, medicines are reported to be the major cause of unintentional poisoning.  The magnitude of the problem is greater in the young age group due to single poison exposure to detergents, antimicrobials, topical preparations, acetaminophen, and scale removers. Pediatric poisoning is more severe in adolescence due to acetaminophen, methylphenidate, non-steroidal anti-inflammatory drugs, atropine, and ethanol. Moderate to severe toxicity is commonly associated with organophosphates, alkali, ethanol, Vipera palaestinae, and neuroleptics. There was a recent report of a fatal attack by a black caiman (Melanosuchusniger) on an 11-year-old child.  However, timely intervention by PEMS can save major catastrophes. 
Accidents are the leading cause of death in children, accounting for more pediatric deaths than all other causes combined. Of all the different accidents, traffic accidents are the major cause of morbidity and mortality. These include involvement of bones, skull and spine fractures, brain injuries. Despite recognition of this major health problem, little emphasis is directed toward the pediatric patient in EMS education. 
Febrile seizures occur in children between the ages of 6 months and 6 years and more in boys.  During febrile seizures, the body becomes stiff, arms and legs begin twitching, breathing is irregular, vomiting, secretions and foam comes out from mouth. The seizures can be fatal, if not taken care of immediately. 
Pediatric respiratory failure
Pediatric respiratory failure is a challenging scenario. It is inadequate gas exchange by the respiratory system, with the result that arterial oxygen and/or carbon dioxide be maintained within their normal ranges. A drop in blood oxygenation is known as hypoxemia and a rise in arterial carbon dioxide levels is hypercapnia. 
Cardiac arrest is the termination of normal circulation of blood due to failure of the heart to contract effectively. The blockade in blood circulation obstructs delivery of oxygen and the lack of oxygen to brain causes loss of consciousness. This results in abnormal breathing. Brain injury can result, if cardiac arrest goes untreated for more than five minutes. It can also lead to early infectious complications. Unexpected cardiac arrests can lead to death, if not given emergent support. ,,
This includes children who have either psychiatric illness or have a behavioral crisis. The treatment includes stabilization and management of patients in mental health crisis, especially after disasters and trauma. 
Traumatic brain injury in children is common, seldom lethal, but has life-long consequences in survivors. Early diagnosis, rational rescue by PEMS and transport of cases to intensive care units of specialized hospitals offer the best chances for reducing mortality and morbidity in severe cases. 
Overdose of drug is the ingestion or application of drug or other substance in quantities greater than recommended. An overdose may result in a toxic state or death. 
Child abuse is the physical, sexual, emotional mistreatment, or neglect of children that results in harm to a child.  It can occur at home or in schools or in communities, the child interacts with. The insults can results in psychological and physical effects, impaired brain development, poor physical health, shaken baby syndrome, and extreme impact can result in rib fractures in an infant secondary to child abuse. 
Groups of PEMS
PEMS is evolved to reflect a change from a system of ambulances that simply provide transportation to a system in which medical care is given not only on the scene, but also during transport.  It is a collective group of services, which include different Pre-Hospital Care Providers (PHCP) according to their expertise in different areas (first aid, emergency medical care, water rescue and extrication, life saving, and ambulance squads). PEMS is summoned by family members, friends, compatriots, on lookers, and members of the public. Whoever is the caller, the First Responder (FR) to the patient is the PHCP. The FR is supposed to be crucial in emergency care of the sick or injured child. 
Techniques involved in PEMS
Good out-of-hospital care determines whether a patient gets an appropriate approach to medical care. In some situations, PEMS units may have to handle rescue operations, including extrication, water rescue, search and rescue; hence, they have to give additional training to PHCP in these tasks. ,, The PEMS task force represent the specialties of trauma, emergency medicine, advanced life-support procedures, intubation and vascular access, endotracheal intubation, vascular access performance, intraosseous infusion, thrombolytic care, defibrillation, airway and ventilator problems, anaphylaxis, intravenous, cannulation, bag-mask ventilation. All the emergency problems are to be attended by PHCP, who is the FR to the emergent situation, and hence it is imperative to educate and train them in all the cores of emergency care. 
Resources and equipment
Although the resources of emergency care system differ from place to place, it is necessary that hospital emergency department staff, administrators, and medical directors agree to implement international guidelines by providing adequate equipment to enhance the effectiveness of the emergency care of children.  The equipment used by these teams is according to the functions carried on; for example, the Basic Life Support (BLS) team would need the following for both infant and child, or pharyngeal airways, bag valve resuscitator, masks for resuscitator, nasal cannulae, oxygen masks, blood pressure cuffs, backboard, cervical immobilization device, extremity splints, burn dressings, sterile scissors, thermal blanket, portable suction unit, suction catheters, tonsil suction tip, bulb syringe. The Advanced Life Support (ALS) team needs the following for both infant and child, monitor defibrillator, laryngoscope with straight and curved blades, pediatric size stylets for endotracheal tubes, pediatric magileforcep, endotracheal tubes, uncuffed and cuffed, arm boards, intravenous catheters, micro drip and macro drip IV devices, and intraoseous needs. ,
Teams of PEMS
Serious and/or life-threatening emergencies for children have the need for exclusive care. Hence, most of the hospital emergency departments have adequate staff with technical know-how of the equipments to bestow effective emergency care for children of all the age groups (from neonates to adolescents). The PEMS personnel are the providers of medical stabilization, which includes the competence to secure an airway, set up a vascular access, intubation, intraosseous line placement, recognize shock and appropriate cardiac rhythm assessment and resuscitation. These personnel get a thorough training on Pediatric Advanced Life Support (PALS). However, a comparison of their skills with those who were untrained revealed that despite better procedural skills, there was no difference in mortality rates between works done by the groups trained and non trained.  This indicates less advantage of training of PALS trained staff and warrants the involvement of pediatricians in the EMS. Training and qualification levels for members and employees of PEMS vary widely throughout the world. Most of the systems have personnel who are at least basic first aid certifications, such as BLS. Moreover, many PEMS systems are staffed with ALS personnel, including paramedics, nurses, and physicians.  The team of PEMS includes the emergency physicians who have additional expertise in PEMS, emergency medical technician, the paramedic, firefighters, and ambulance employees.  The levels of service available will fall into one of three categories; BLS, ALS, and care by traditional healthcare professionals, (nurses and/or physicians) working in the pre-hospital setting and even while on ambulances. The clinical effectiveness of ALS over BLS is only for patients with certain pathologies.  In some countries, the PEMS will include administrative secretaries, municipality nurses and social care workers, in addition to unskilled workers to assist patient transport duties (stretcher or wheelchair cases). ,
Role of pediatricians
Pediatricians are in the front lines of Pediatric Emergency Care and are considered the experts in the management and supervision of PEMS. They can bestow clinical expertise, in addition to making available education about management and preclusion of pediatric sickness, appropriate equipment for the intensely ill, and/or injured child and their rehabilitative care. Furthermore, the pediatrician will be a link between all the bodies working with children and can establish clinical protocols. , Hence, the services of pediatricians for the betterment of PEMS are indispensable. Although, there is a need for the involvement of faculty and fellows of teaching hospitals with a fellowship of Pediatric Emergency Medicine to improve PEMS, in pre-hospital care, but unfortunately, there appears to be little involvement of these experts in the PEMS settings. The PEM fellowship curriculum guidelines for training in PEMS are not being met by majority of the responding training programs.  The PALS course teaches the fundamental basics for pediatric emergency care, and it is recommended that all pediatricians, physicians, nurses, and paramedics who care for children complete training and refresher courses on a regular basis. However, majority of those who participated in PALS training were neither pediatricians nor physicians. 
Drawbacks of PEMS
Children who are seriously injured, ill, or incapacitated have different medical needs than adults. Their rates of heart, respiration, and blood pressures are different; they often need smaller equipment than what is used for adults, and they require carefully calculated medicine. However, despite of the increased demand for pediatric exigencies, many EMS agencies are not well equipped to handle these patients. A large number of weaknesses are recorded in PEMS system; however, the more in depth drawbacks, such as, equipment provision, ignorance, and lack of expertise and ignorance and common drawbacks confronting medical exigencies will follow the ambulance and transport system, which is the primary necessity of different emergencies.
Ambulance and transport
There is a general consensus that the ambulance units are not sufficient to cater the needs of emergencies. This was the most common complaint from parents and guardians of pediatric patients, who were in dire need due to severe exigencies.  The mismanagement is more common in rural jurisdictions. A comparison of transporting the sick children between urban and rural jurisdictions, revealed that the response and transport times of major trauma incidents by ALS-trained paramedics are longer in the latter,  this shows that the transport facilities at rural levels needs a lot of improvement. A sizeable number of ambulance crashes are reported that cause additional emergencies to the transported patients. The reckless driving stems from improper education and counseling , and improved education may help the safe transport of the pediatric patients to the emergency departments of different hospitals. Although there is no need to use ambulance for smaller children, but improper decisions on non-ambulance transport in the system cannot compromise, keeping the ambulance busy and wastes time. Sacchetti et al.  were of the opinion that small children and infants do not require stretchers or ambulances for transport from a pre-hospital scene to the emergency department, unless there is a need for the equipment inside a regular ambulance. Often the management of ambulance transport of patients is left to the discretion of the drivers or the paramedics; this is a serious lacuna on the part of the PEMS. When the responsibility for management of pre-hospital emergency care is left to the discretion of paramedical staff, they are not shown to be responsible. In a study on non-transported pediatric patients, Kahale et al.  observed that 28% of children cared for by paramedics were not transported to hospital by ambulance. Enrolled were all children aged <16 years assessed by paramedics but not transported to hospital over a five-month period, despite of a true emergency like trauma and medical causes.
In a study to evaluate the availability of important pediatric resuscitation equipment in emergency ambulances, it was found that the different necessities (face masks, self inflating bags, pediatric oximeter probes) were not adequately provided. 
Ignorance and lack of expertise
The major drawbacks, weaknesses and obstacles of PEMS are the practical difficulties in the service provisions. These are unrecognized needs for ventilator support, added oxygen, chest X-ray or nasogastric tube, and the difficulties with airway selection, placement, and care. A study on assessment of service provision to children in a pre-hospital and/or emergency services set up, revealed 81% respondents to claim that paramedics and most of the emergency medical technicians have a limited pediatric training. At least 54% respondents were of the opinion that in emergency, the first response to a child is with someone who is educationally and training wise incompetent.  In majority of the instances, the know-how for equipment is lacking, despite of their availability. In a study to evaluate the extent of paramedic training in pediatric resuscitation, it was found that they are ill prepared to deal with pediatric emergencies due to lack of proper training. 
Decreased opportunity to successfully completed high risk technical skills and experiences are another drawback for the paramedics to lag behind in management of critically ill pediatric patients.  Qazi et al.  reported that role of paramedic judgments for trauma team activation is not clearly defined and they emphasized on the need for further elaboration in this regard. In matter of the care of the life-threatening emergencies, Eich et al.  are of the opinion that these emergencies are not routine procedures for non-specialized emergency physicians and hence, even they feel insecure and are fearful to handle such cases. The authors felt that the physicians need adequate training before they are exposed to severe type of emergencies. In a study on comparison between physician-staffed ALS units and BLS units staffed by emergency medical technicians, Suominen et al.  found that the outcome of severe blunt trauma in children receiving pre-hospital care in the former group was much better than the latter. This shows that the personnel trained in BLS and the emergency medical technicians, needs more education and training in blunt trauma to get perfection.
Cook et al.  reported that abdominal CT scans of pediatric blunt trauma on repeating showed that 80% are potentially preventable, if the PEMS personnel (paramedics, emergency medical technicians, nurses and EMS physicians) would have had better education and training. There are several substances, including medications that can result in significant toxicity or death; however, most of the pre-hospital providers are not familiar with dose and complications of different drugs. This is a major drawback of the technical staff of PEMS. Hence, it is imperative that the pre-hospital providers be aware of the dose and toxicity, in addition to generic and trade names of these medications. 
Airway management is a major component of pre-hospital management for seriously ill and injured patients. A study on meta-analysis of pre-hospital airway control techniques conducted by Hubble et al.  revealed that the safety and efficacy profile of pre-hospital intubation has been challenged on the basis of varying intubation success rates and paucity of established benchmarks. Proficiency in airway management in children is difficult to acquire by the pre-hospital providers. 
End-tidal carbon dioxide (ETCO2) monitoring is useful in verifying endotracheal tube position during cardiopulmonary resuscitation. There are reports that the paramedics are unable to properly place the endotracheal tubes in the pre-hospital setting. In a report on ETCO2 monitoring, Bhende and LaCovery,  asserted that the paramedics should learn correct techniques of endotracheal intubation. A comparison of EMS between adult and children in Oklahoma revealed fewer services that allow personnel to perform endotracheal intubation on children than on adults. To start intravenous lines on children, fewer services were available on children than on adults. In the intra-agency continuing education, only 54% included pediatric topics. Thus, deficiencies in equipment and training for pediatric emergencies are a common problem for EMS agencies.  Although paramedics had an 84% success rate at establishing intravenous lines in children in the field, half the children were younger than 6 years and required intravascular access, failed to receive an IV line in the pre-hospital setting. Multiple IV line attempts must be discouraged because additional attempts are expensive and may extend transport times.  The need for peripheral IV is of great importance in order to give drugs and fluids in pediatric emergencies. This is reported to fail in up to 50% of children younger than 6 years. When the IV access is failed, the next step according to the international guidelines is the intraosseous (IO) access. Despite of intense training and workshops conducted on skills in IO, there was no increase in the success rate of this technique. 
Multiple deficiencies in the performance of pediatric resuscitation skills of paramedics included lack of airway support or protection, lack of support of ventilations or cardiac function, inappropriate use of length-based treatment tapes and inaccurate calculation and administration of medications and fluids.  The authors suggested that the educators and directors of PEMS should target these specific skill deficiencies when developing continuing education in pre-hospital pediatric patient care. Often the EMS providers are hesitant to perform the mouth-to-mouth resuscitation (MMR) with or without a barrier. This appears to be perhaps because of their perception of a high risk of contagion.  and this reluctance is a major setback in performance of their duties.
Common drawbacks confronting medical exigencies
The most common etiologies in most of the mortalities were sudden infant death syndrome, trauma, respiratory, and submersions. Literature reports suggest that cardiopulmonary resuscitation, did not demonstrate to result in improved survival rates in these emergencies. Arrest rhythms were a systole pulse less electrical activity, and ventricular fibrillation and children with the latter 2 rhythms had better survival rates. Young et al.  reported a minimum of 8.6% survival rate among in 599 patients of out-of-hospital cardiopulmonary arrest, which is very poor. Administration of >3 doses of epinephrine or prolonged resuscitation was found to be unsuccessful. Adequate training and expertise of the pre-hospital providers would increase the survival rate.
Studies on endotracheal intubation, intravascular access, and administration of epinephrine, showed that these procedures were attempted and performed less frequently in children than in adults. From this study, the authors concluded that the pre-hospital providers need additional training to maintain their skills in children's cardiopulmonary arrest.  In a study on pre-hospital victims of medical cardiopulmonary arrest under the age of 19 years, Aijian et al.  found that majority of the endotracheal intubation attempts made by paramedics were unsuccessful.
Pediatric respiratory arrest is a challenging scenario faced by pre-hospital providers. Pre-hospital endotraceal intubation is a complex procedure that sometimes results in worse neurological complication in these patients. Alternatives to pre-hospital endotracheal intubation include bag-valve-mask ventilation and the laryngeal mask airway. Pre-hospital providers were able to place and ventilate a simulated pediatric respiratory arrest patient, but obvious air leakage was noted when ventilating with the laryngeal mask airway. 
Acute asthma exacerbations are life threatening. Although the EMS personnel can recognize these symptoms, the therapies and medications which they can use are limited. Several studies have demonstrated the effective use of β-2 agonist therapy in the treatment of patients complaining of wheezing or dyspnea, yet few PEMS personnel can administer them.  The authors are of the opinion that PEMS personnel should be trained to administer β-2 agonists to patients with acute asthma exacerbations. Advance level of emergency medical training and additional hours of continuing medical education were found to influence the increased comfort levels felt by Emergency medical technicians, when confronting a pediatric emergency.  Despite national guidelines from the Joint Royal Colleges Ambulance Liaison Committee (JRCALC), the tendency of escalating the standards of paramedic practice among adult patients have not extended to pediatric practice. The JRCALC guidelines for the supervision of life threatening pediatric emergencies, such as asthma, meningitis, and fluid replacement in hypovolaemia are not been adhered to. Ambulance Trusts are not meeting standards set out in the JRCALC guidelines. All these drawbacks endanger children's lives and are open for criticism.  Prescribing epinephrine, educating the parents of their responsibility to implement deterrence strategies both in and outside the home environment, and developing written plans to reduce the risk of anaphylaxis and to execute emergency treatment in the event of an allergic reaction is a subject of a pediatrician and it is not safe to leave such emergencies in the hands of non-clinical PEMS staff. 
The history and physical examination of patients will classify the patients as having a "simple febrile seizure" which lowers the risk of any potential negative outcome. Brodsky et al.  reported that simple febrile seizure patients are suitable for transport via BLS. But the authors are skeptical of the performance of PHCP (a non-clinician); even to identify the simple and/or complex febrile seizure. Dieckmann et al.  considered PEMS for children to be feebly developed constituent of EMS systems, as compared to the adults. The authors listed that there is dire need of improving all segments of pediatric emergency, including trauma and critical care.
Pre-hospital care has been considered as one of the factors in the variations that results in the outcome of severe brain injury in children. It is felt that effective pre-hospital management and emergency care at the scene of injury and during transport by paramedics is feebly developed and cannot influence mortality rates in severely brain-injured children.  Hennes et al.  reported inability of emergency medical technicians to assess acute pain in children and adolescents to be the most common barrier for provision of analgesia.
King et al.  found that many emergency medicine technicians and paramedics lack a complete understanding of their role in the identification and reporting of child abuse. This information should be reinforced through continuing education. Although the pre-hospital providers expressed confidence in recognition and management of child abuse, significant deficiencies were reported in critical knowledge areas, including identification of maltreatment, interviewing techniques, and appropriate documentation. 
| Conclusions|| |
Young people who are sick or injured and require immediate care have unique medical needs, but many PEMS are not fully prepared to care for pediatric emergencies. To strengthen the pediatric emergency care, hospitals around the country should make common guidelines and adhere to them strictly.
- All transport coordinators should review the qualifications and experience of their team to assess their ability to provide optimal care for the children they transport.
- Regular reviews of performance of all Pediatric Emergency Transport Services (PETS), can improve the weaknesses in the organization of PETS and hence, the patient outcome
- The pre-hospital care providers (emergency medical technicians and transport teams) in the field should be highly educated, well trained and skilled in the specific procedures of PEMS. A PEMS-trained physician is supposed to be with the team always.
- Meetings of pre-hospital and hospital-based providers should be conducted periodically to discuss the management of challenging cases.
- The care centers for emergency dealing with visits to call should endeavor for quality care through organized record keeping, chart reviews, and audits identifying the deficiencies and appropriate remedies.
- There is a need to establish networks of co-operation between the pediatricians and experts of hospital emergency department and the team of pre-hospital providers.
- Comprehensive pediatric emergency care has to involve integration of emergency stabilization patient care with community and hospital social services, patient education and rehabilitation programs, as well as community accident prevention and basic life support programs to assure optimal outcome for life-threatened children.
- Public health agencies are required to work with the PEMS systems to develop and deliver training with an all-hazards approach to disasters and other public health emergencies.
- Although intensive out-of-hospital pediatric education increase awareness and expertise, but this is not retained for long. Hence, emergency medical services programs should find innovative ways to increase retention and ensure paramedic readiness.
| Acknowledgments|| |
The author is thankful to the administration of King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia for providing facilities. My thanks are due to the Director of Libraries, King Saud University, for providing all the library facilities. I am thankful to the system administrators of different sites including; PubMed, PubMed Central, Science Direct, Up-to-date, Medline, comprehensive databases, Cochrane library, Internet (Google, Yahoo), and many other websites which were useful for gathering useful information in the write up.
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Abdullah Foraih Al-Anazi
Department of Pediatric Emergency, King Saud Bin Abdulaziz University for Health Sciences, Riyadh
Kingdom of Saudi Arabia
Source of Support: King Saud Bin Abdulaziz University For Health Sciences, Conflict of Interest: None