¿A qué edad está indicado iniciar el tratamiento con glucocorticoides en un paciente diagnosticado con Distrofia Muscular de Duchenne?

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Duchenne y el síndrome de Guillain-Barré. La poliomielitis natural es predominantemente causada por el serogrupo tipo 1. El pilar del tratamiento sintomático de la mielitis transversa en fase aguda es la metilprednisolona a dosis altas. ### Poliomielitis y Mielitis Transversa La **poliomielitis** es una enfermedad infecciosa causada por el poliovirus, un enterovirus de la familia *Picornaviridae*. De sus tres serotipos (1, 2 y 3), el serotipo 1 es el agente etiológico más común aislado en los casos de poliomielitis paralítica natural o salvaje. Afección caracterizada por la destrucción selectiva de las motoneuronas de las astas anteriores de la médula espinal y los núcleos motores del tronco encefálico, ocasionando una parálisis flácida asimétrica progresiva con hiporreflexia o arreflexia. Por otro lado, la **mielitis transversa** es un trastorno desmielinizante focal de la médula espinal que interrumpe la conducción motora, sensitiva y autonómica. El pilar farmacológico de ataque en el manejo de la mielitis transversa aguda es la **metilprednisolona** por vía intravenosa a dosis altas (habitualmente $30\text{ mg/kg/día}$ durante $3 \text{ a } 5\text{ días}$). ### Enzimas Musculares y Distrofia Muscular de Duchenne La **creatina quinasa (CK)** es un marcador enzimático fundamental en el abordaje de miopatías. Su valor normal en plasma es generalmente $<160\text{ UI/L}$. Elevaciones masivas de CK (a menudo superiores a $10,000\text{ UI/L}$) son altamente sugerentes de miopatías distróficas destructivas. La **distrofia muscular de Duchenne (DMD)** es una enfermedad recesiva ligada al cromosoma X provocada por mutaciones en el gen que codifica la proteína distrofina. 1. **Detección del retraso motor:** Los signos iniciales aparecen habitualmente entre los 2 y 3 años de edad (marcha de pato, signo de Gowers positivo). 2. **Meseta o regresión en el desarrollo:** Entre los 4 y 6 años de edad, el niño alcanza una meseta en el desarrollo motor o inicia un deterioro en comparación con sus pares. 3. **Inicio de corticoide:** El inicio del tratamiento con esteroides (como deflazacort o prednisona) está indicado cuando se identifica la meseta o regresión motora, típicamente entre los 4 y 6 años de edad. Retrasar el inicio del tratamiento con esteroides más allá del periodo de meseta motor reduce la eficacia preservadora del tejido muscular funcional y acelera la pérdida de la deambulación independiente. ### Síndrome de Guillain-Barré (SGB) El **síndrome de Guillain-Barré** es una polirradiculoneuropatía inflamatoria aguda de origen autoinmune, frecuentemente desencadenada por una infección previa. La debilidad neuromuscular alcanza su máxima gravedad o punto cénit dentro de las primeras **4 semanas** tras el inicio de los síntomas. - **AIDP:** Polineuropatía desmielinizante inflamatoria aguda (la más frecuente). - **AMAN:** Neuropatía axónica motora aguda. - **AMSAN:** Neuropatía axónica sensitivo-motora aguda. - Encefalitis troncoencefálica de Bickerstaff (ETB) - Polineuritis craneal (PC) - Variante faríngea-cervical-braquial (FCB) - Neuropatía sensorial aguda - Pandisautonomía aguda - Oftalmoparesia aguda - Paraparesia Característica | Guillain-Barré Típico | Variante Faríngea-Cervical-Braquial Compromiso motor | Asendente, extremidades inferiores | Bulbar, cuello y miembros superiores Fase cénit | $\le 4\text{ semanas}$ | $\le 4\text{ semanas}$ Reflejos osteotendinosos | Hiporreflexia o arreflexia generalizada | Arreflexia focal o descendente ¿A qué edad está indicado iniciar el tratamiento con glucocorticoides en un paciente diagnosticado con Distrofia Muscular de Duchenne? El consenso clínico establece iniciar esteroides cuando el niño entra en la meseta o regresión funcional motora respecto a sus pares, lo cual se presenta habitualmente entre los 4 y 6 años de edad. ¿Cuál es la variante de SGB caracterizada por encefalopatía, ataxia y oftalmoplejía con alteración de la conciencia? Encefalitis troncoencefálica de Bickerstaff (ETB). El serotipo 1 del poliovirus causa la mayoría de casos de poliomielitis natural. La mielitis transversa se maneja con metilprednisolona. La CK normal es $<160\text{ UI/L}$. El tratamiento con esteroides en Duchenne se inicia de los 4 a 6 años. El cénit de debilidad en Guillain-Barré ocurre a las 4 semanas. ------ ## Manejo del Accidente Ofídico en Pediatría Aprender la fisiopatología, origen y administración del suero antiofídico en Centroamérica, el impacto de las toxinas sobre la cascada de coagulación y las especies de serpientes relevantes en El Salvador. El suero antiofídico utilizado en El Salvador proviene del Instituto Clodomiro Picado de Costa Rica. La serpiente involucrada en mordeduras con mayor frecuencia en este país es la cascabel. ### Origen y Dilución del Suero Antiofídico Los sueros antiofídicos son inmunoglobulinas purificadas derivadas del plasma de equinos o bovinos hiperinmunizados con venenos de serpientes específicas. En El Salvador y el resto de la región centroamericana, los sueros estandarizados son producidos por el **Instituto Clodomiro Picado** de la Universidad de Costa Rica. Preparaciones parenterales destinadas a neutralizar las toxinas del veneno. El antiveneno anticoral neutraliza toxinas de la familia *Elapidae*, mientras que el polivalente actúa contra la familia *Viperidae* (gneros *Bothrops*, *Crotalus*, *Lachesis*). Para la dilución e infusión del antídoto en caso de mordedura de serpiente: 1. **Dosis inicial:** Se preparan de 5 a 10 frascos de suero anticoral o polivalente según el cuadro clínico y el veneno sospechado. 2. **Volumen de dilución en Solución Salina Normal (SSN):** - **Adultos:** Diluir en $400 \text{ a } 500\text{ ml}$ de SSN. - **Niños:** Diluir en $200\text{ ml}$ de SSN. 3. **Tasa de infusión:** Iniciar a una velocidad lenta de $10\text{ gotas/minuto}$ para vigilar reacciones anafilácticas o de sobrecarga hídrica. 4. **Dosis máxima:** No sobrepasar la cantidad total de $20\text{ frascos}$ en $24\text{ horas}$. Exceder la velocidad de infusión inicial recomendada puede provocar anafilaxia masiva o sobrecarga hídrica, especialmente en pacientes pediátricos con compromiso hemodinámico. ### Fisiopatología del Veneno sobre la Coagulación El veneno de vipers como *Bothrops* (terciopelo) y *Lachesis* destruye el sistema de hemostasia alterando proenzimas y zimógenos clave. ```mermaid flowchart TD Veneno["Veneno de Bothrops / Lachesis"] --> Batroxobina["Batroxobina"] Veneno --> Trombocitina["Trombocitina"] Veneno --> FXAct["Activadores Directos de FX"] Batroxobina --> Fibrinogeno["Transforma Fibrinógeno en Fibrina"] Trombocitina --> PlaqFXII["Activa Plaquetas y Factor XII"] FXAct --> FXa["Activa Factor X a FXa"] Fibrinogeno --> CID["Hipercoagulabilidad -> Consumo de Fibrinógeno -> CID"] PlaqFXII --> CID FXa --> CID ``` Los componentes de la coagulación afectados incluyen: * **Factor XII, Factor X y Fibrinógeno:** Alterados de forma directa por toxinas proteolíticas. * **Batroxobina:** Enzima similar a la trombina que consume el fibrinógeno. * **Trombocitina:** Activa de forma anómala plaquetas y el Factor XII. * **Factores V y VI:** Intervienen en la activación del Factor X, desencadenando coagulación intravascular diseminada (CID). En relación con la hemostasia normal, los factores de coagulación **dependientes de vitamina K** son los factores $II$, $VII$, $IX$ y $X$, junto con las proteínas anticoagulantes endógenas **C** y **S**. ### Identificación Epidemiológica y Morfológica En El Salvador, la serpiente que provoca mordeduras con mayor frecuencia es la **cascabel** (*Crotalus simus*). Para la diferenciación rápida entre corales verdaderas y falsas corales se utiliza el patrón cromático de sus anillos corporales: Especie | Patrón de Colores Anulares | Peligrosidad Coral Verdadera (*Micrurus*) | Anillo **negro** dispuesto entre dos anillos **amarillos** (patrón RANA) | Veneno neurotóxico altamente letal Falsa Coral (*Erythrolamprus*, etc.) | Anillos amarillos separados de los negros por anillos rojos u otros patrones | Generalmente no venenosa o no pautada ¿Cuáles son los factores de coagulación cuya síntesis adecuada depende de la presencia de Vitamina K? Los factores de coagulación dependientes de la vitamina K para su carboxilación hepática son los factores II (prototrombina), VII, IX, X y las proteínas reguladoras anticoagulantes C y S. ¿Cómo se diluye y administra la dosis de suero antiofídico en un paciente pediátrico? 5 a 10 frascos en 200 ml de Solución Salina Normal (SSN), iniciando a 10 gotas/minuto. El suero antiofídico centroamericano procede del Instituto Clodomiro Picado. La especie con más mordeduras en El Salvador es la cascabel. La coral verdadera tiene una franja negra entre dos amarillas. Los factores dependientes de vitamina K son II, VII, IX, X y proteínas C y S. ------ ## Dengue Pediátrico y Manejo Hemodinámico Comprender la evaluación clínica del dengue con signos de alarma, la identificación del estado de choque latente o manifiesto y la reanimación hídrica parenteral calculada por peso corporal. La dosis inicial de reanimación hídrica por vía intravenosa en un paciente pediátrico con dengue que presenta signos de alarma o extravasación es de 10 ml/kg a pasar en una hora. ### Evaluación Clínica y Fases del Dengue El **dengue** es una enfermedad viral febril transmitida por mosquitos del género *Aedes*. Presenta tres fases bien definidas: febril, crítica y de recuperación. Aparición de dolor abdominal intenso, vómitos persistentes, acumulación clínica de líquidos, sangrado de mucosas (epistaxis, gingivorragia), letargia o irritabilidad, hepatomegalia $>2\text{ cm}$ e incremento progresivo del hematocrito junto con trombocitopenia. En el caso de un paciente que cursa con fiebre, leucopenia, trombocitopenia y manifestaciones hemorrágicas leves o moderadas (epistaxis), nos encontramos ante un cuadro de dengue con signos de alarma. ### Cálculo de Terapia Fluidoterápica Inicial Cuando un paciente pediátrico diagnosticado con dengue presenta signos de extravasación plasmática o sangrado (como epistaxis repetida), está indicada la expansión rápida de volumen intra vascular para prevenir el choque hipovolémico. Para un paciente con un peso corporal de $24\text{ kg}$: * **Indicación:** Dosis intravenosa inicial de solución cristaloides (Solución Salina Normal al $0.9\%$ o Lactato de Ringer). * **Dosis estándar de carga:** $10\text{ ml/kg/hora}$. * **Cálculo:** $$24\text{ kg} \times 10\text{ ml/kg} = 240\text{ ml}$$ * **Administración:** Se administran $240\text{ ml}$ en bolo IV a infundir en un período estricto de $1\text{ hora}$. ```mermaid flowchart LR Diag["Dengue con Signos de Alarma"] --> Peso["Evaluación de peso (24 kg)"] Peso --> Dosis["Dosis: 10 ml/kg/hora"] Dosis --> Bolo["Infusión inicial: 240 ml IV en 1 hora"] Bolo --> Reeval["Reevaluación clínica e incremento/reducción de líquidos"] ``` Administrar cargas hídricas mayores o no controlar la velocidad de infusión durante la fase crítica del dengue puede provocar sobrecarga hídrica, edema agudo de pulmón y derrame pleural masivo en la fase de reabsorción. Un paciente de 24 kg requiere una carga intravenosa inicial por signos de alarma de dengue. ¿Cuál es la dosis y tiempo de infusión indicado? La guía clínica estandarizada para la reposición hídrica en dengue con signos de alarma establece iniciar con una solución de cristaloides a razón de 10 ml/kg a infundir en 1 hora. ¿Cuál es la tasa inicial de líquidos intravenosos en dengue con signos de alarma? 10 ml/kg infundidos en 1 hora. El dengue requiere vigilancia estrecha durante la fase crítica. Ante sangrados o signos de extravasación en un paciente con dengue, la dosis de reanimación hídrica IV de primera línea es de $10\text{ ml/kg}$ infundida en $1\text{ hora}$. 5:["$","$L29",null,{"value":{"GET /exams/6a81ee6fffd1c9a62188bbeb":{"user":{"id":"6a81d3b3c3462fd0b1ac9281","username":"keyliwis"},"exam":{"questions":[{"id":"0df66c53-133a-468c-b02b-77b936358126","original_quiz_id":"6a81ee6fffd1c9a62188bbeb","created":"$D2026-08-16T17:27:52.578Z","description":"1. 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Esto generalmente ocurre entre los 4 y 6 años de edad"},{"id":"D","text":"A partir de los 10 años cuando pierde la deambulación"}],"correctOptions":["C"],"matches":[],"match_pairs":[],"explanation":"El inicio de los esteroides está indicado cuando un niño alcanza una meseta en el desarrollo y/o una regresión en el desarrollo motor en comparación con sus compañeros. Esto generalmente ocurre entre los 4 y 6 años de edad","helpful_links":[],"tags":[]},{"id":"7379d98b-a860-43ee-96d8-48d0856ed882","original_quiz_id":"6a81ee6fffd1c9a62188bbeb","created":"$D2026-08-16T17:27:52.578Z","description":"6. En cuanto tiempo se alcanza la debilidad máxima en Guillén-Barre?","questionContent":"Debilidad máxima en Guillén-Barre","questionImage":null,"type":"single","options":[{"id":"A","text":"Se alcanza a las 24 horas después del inicio."},{"id":"B","text":"Se alcanza a las 2 semanas después del inicio."},{"id":"C","text":"Se alcanza a las 4 semanas después del inicio."},{"id":"D","text":"Se alcanza a los 3 meses después del inicio."}],"correctOptions":["C"],"matches":[],"match_pairs":[],"explanation":"Se alcanza a las 4 semanas después del inicio.","helpful_links":[],"tags":[]},{"id":"53e0f6a7-1f5d-4943-8718-bd10f85769ad","original_quiz_id":"6a81ee6fffd1c9a62188bbeb","created":"$D2026-08-16T17:27:52.578Z","description":"7. Variantes de Guillén-Barre (complementar):","questionContent":"Variantes de Guillén-Barre","questionImage":null,"type":"single","options":[{"id":"A","text":"● Encefalitis troncoencefálica de Bickerstaff (ETB)\n● Polineuritis craneal (PC)\n● Variante faríngea-cervical-braquial (FCB)\n● Neuropatía sensorial aguda\n● Pandisautonomía aguda\n● Oftalmoparesia aguda\n● Paraparesia"},{"id":"B","text":"● Esclerosis lateral amiotrófica\n● Miastenia gravis\n● Síndrome de Eaton-Lambert\n● Neuropatía motora multifocal"},{"id":"C","text":"● Polineuropatía diabética\n● Síndrome de Charcot-Marie-Tooth\n● Ataxia de Friedreich\n● Paraparesia espástica hereditaria"},{"id":"D","text":"● Radiculopatía lumbosacra\n● Síndrome del túnel carpiano\n● Mononeuritis múltiple\n● Polineuropatía alcohólica"}],"correctOptions":["A"],"matches":[],"match_pairs":[],"explanation":"● Encefalitis troncoencefálica de Bickerstaff (ETB)\n● Polineuritis craneal (PC)\n● Variante faríngea-cervical-braquial (FCB)\n● Neuropatía sensorial aguda\n● Pandisautonomía aguda\n● Oftalmoparesia aguda\n● Paraparesia","helpful_links":[],"tags":[]},{"id":"a5f994cb-57fe-48f7-8de3-a8a476e70c0c","original_quiz_id":"6a81ee6fffd1c9a62188bbeb","created":"$D2026-08-16T17:27:52.578Z","description":"8. Epidemiología de accidente ofídico","questionContent":"Epidemiología de accidente ofídico","questionImage":null,"type":"single","options":[{"id":"A","text":"Distribución universal sin variabilidad geográfica"},{"id":"B","text":"Mayor frecuencia en áreas rurales y agrícolas con variaciones de especies según la región"},{"id":"C","text":"Afectación exclusiva en adultos del sexo femenino"},{"id":"D","text":"Predominio absoluto de mordeduras por serpientes marinos"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"El accidente ofídico predomina en zonas rurales y agrícolas según la distribución epidemiológica local.","helpful_links":[],"tags":[]},{"id":"941a7ec5-8254-428f-9bc5-3961c7b17fad","original_quiz_id":"6a81ee6fffd1c9a62188bbeb","created":"$D2026-08-16T17:27:52.578Z","description":"9. De donde se obtiene el suero antiofídico que se utiliza en El Salvador?","questionContent":"Origen del suero antiofídico","questionImage":null,"type":"single","options":[{"id":"A","text":"Los sueros antiofídicos son preparaciones de anticuerpos obtenidos del plasma de equinos del Instituto Butantan de Brasil."},{"id":"B","text":"Los sueros antiofídicos son preparaciones de anticuerpos obtenidos del plasma de caballos o de ovejas hiperinmunizados con venenos de serpientes de la zona geográfica respectiva, es así que los sueros a usar para las mordeduras de serpientes de Centroamérica son los sueros producidos en el Instituto Clodomiro Picado de Costa Rica."},{"id":"C","text":"Son sintetizados biotecnológicamente en los laboratorios centrales del Ministerio de Salud de El Salvador."},{"id":"D","text":"Se obtienen a partir de suero humano de donantes convalecientes en el Instituto Pasteur."}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Los sueros antiofídicos son preparaciones de anticuerpos obtenidos del plasma de caballos o de ovejas hiperinmunizados con venenos de serpientes de la zona geográfica respectiva, es así que los sueros a usar para las mordeduras de serpientes de Centroamérica son los sueros producidos en el Instituto Clodomiro Picado de Costa Rica.","helpful_links":[],"tags":[]},{"id":"04ac38e0-eb5c-43c4-8525-7b2f3c6747b0","original_quiz_id":"6a81ee6fffd1c9a62188bbeb","created":"$D2026-08-16T17:27:52.578Z","description":"10. En cuanto se diluye el antídoto?","questionContent":"Dilución del antídoto antiofídico","questionImage":null,"type":"single","options":[{"id":"A","text":"un frasco en 100 ml de SSN a pasar en 15 minutos en bolo directo"},{"id":"B","text":"cinco a diez frascos del suero anticoral (para elapidae) o polivalente (para vipiridae o hidropidae) en adulto 400 - 500 ml y en niños en 200 ml de SSN; para evitar sobrecaga, iniciar a diez gotas/minuto. No exceder de veinte frascos en veinticuatro horas."},{"id":"C","text":"veinte frascos diluidos en 1000 ml de Solución Glucosada al 5% a pasar a 60 gotas/minuto"},{"id":"D","text":"diez frascos en 50 ml de agua destilada a pasar a 20 gotas/minuto"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"cinco a diez frascos del suero anticoral (para elapidae) o polivalente (para vipiridae o hidropidae) en adulto 400 - 500 ml y en niños en 200 ml de SSN; para evitar sobrecaga, iniciar a diez gotas/minuto. No exceder de veinte frascos en veinticuatro horas.","helpful_links":[],"tags":[]},{"id":"36cefc50-1826-4542-8edd-1f3e40a960c8","original_quiz_id":"6a81ee6fffd1c9a62188bbeb","created":"$D2026-08-16T17:27:52.578Z","description":"11. Factores de coagulación que alteran los venenos:","questionContent":"Factores alterados por venenos","questionImage":null,"type":"single","options":[{"id":"A","text":"El veneno altera únicamente la agregación plaquetaria sin afectar la cascada de la coagulación"},{"id":"B","text":"El veneno de Bothrops y Lachesis afecta el fibrinógeno, factor XII y factor X. La batroxobina transforma el fibrinógeno en fibrina, la trombocitina activa las plaquetas y el factor XII, y los factores V y VI activan directamente el factor X. Esto provoca hipercoagulabilidad, consumo de fibrinógeno y finalmente coagulación intravascular diseminada."},{"id":"C","text":"El veneno bloquea únicamente el factor VIII causando hemofilia adquirida transitoria"},{"id":"D","text":"El veneno destruye exclusivamente la protrombina e inhibe a la proteína C y S"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"El veneno de Bothrops y Lachesis afecta el fibrinógeno, factor XII y factor X. La batroxobina transforma el fibrinógeno en fibrina, la trombocitina activa las plaquetas y el factor XII, y los factores V y VI activan directamente el factor X. Esto provoca hipercoagulabilidad, consumo de fibrinógeno y finalmente coagulación intravascular diseminada.","helpful_links":[],"tags":[]},{"id":"401bd585-0258-4cf0-a3fd-a653f7778816","original_quiz_id":"6a81ee6fffd1c9a62188bbeb","created":"$D2026-08-16T17:27:52.578Z","description":"12. Factores de la coagulación dependientes de vitamina K:","questionContent":"Factores K-dependientes","questionImage":null,"type":"single","options":[{"id":"A","text":"son I, V, VIII, XIII y antitrombina III"},{"id":"B","text":"son II, VII, IX, X y las proteínas anticoagulantes C y S"},{"id":"C","text":"son III, IV, XI, XII y cofactor de heparina"},{"id":"D","text":"son V, VIII, IX, XI y plasminógeno"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"son II, VII, IX, X y las proteínas anticoagulantes C y S","helpful_links":[],"tags":[]},{"id":"b269652e-8277-4bf7-b8aa-b6fc790934b5","original_quiz_id":"6a81ee6fffd1c9a62188bbeb","created":"$D2026-08-16T17:27:52.578Z","description":"13. La mordedura de qué serpiente es más frecuente en El Salvador:","questionContent":"Frecuencia de mordedura en El Salvador","questionImage":null,"type":"single","options":[{"id":"A","text":"Coral"},{"id":"B","text":"Tamagás"},{"id":"C","text":"Cascabel"},{"id":"D","text":"Masacuata"}],"correctOptions":["C"],"matches":[],"match_pairs":[],"explanation":"Cascabel","helpful_links":[],"tags":[]},{"id":"c9701ee0-324a-4d5b-9b17-f7c4e1363901","original_quiz_id":"6a81ee6fffd1c9a62188bbeb","created":"$D2026-08-16T17:27:52.578Z","description":"14. Cómo distinguir un coral verdadero de un falso:","questionContent":"Diferencia coral verdadero vs falso","questionImage":null,"type":"single","options":[{"id":"A","text":"Por la forma de las escamas dorsales"},{"id":"B","text":"Por la presencia de orificios fosetos nasales"},{"id":"C","text":"Por los colores (el verdadero tiene una franja negra entre dos franjas amarillas)"},{"id":"D","text":"Por el diámetro corporal y la longitud de la cola"}],"correctOptions":["C"],"matches":[],"match_pairs":[],"explanation":"Por los colores (el verdadero tiene una franja negra entre dos franjas amarillas)","helpful_links":[],"tags":[]},{"id":"43f0f10c-61c0-4cfd-aec1-2af73f2dc579","original_quiz_id":"6a81ee6fffd1c9a62188bbeb","created":"$D2026-08-16T17:27:52.578Z","description":"15. Un niño de 6 años, pesa 24 kg, 4 dias de fiebre, malestar general, osteomialgia. Se le toma un hemograma el dia de ayer con blancos de 4,300, hemoglobina de 13, hematocrito de 39.6, plaquetas de 89,000, medicado con acetaminofén, presenta epistaxis en dos ocasiones por lo cual decide consultar. F.C: 90, PA:100/70, SAT: 96% con FiO al 21%, FR: 20. ¿Cuál es el diagnóstico?","questionContent":"Caso clínico de dengue","questionImage":null,"type":"single","options":[{"id":"A","text":"Dengue sin signos de alarma"},{"id":"B","text":"Dengue con signos de alarma"},{"id":"C","text":"Dengue grave con choque hipovolémico"},{"id":"D","text":"Chikungunya agudo con trombocitopenia"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La presencia de sangrado de mucosas (epistaxis) junto a la trombocitopenia clasifica el cuadro como dengue con signos de alarma.","helpful_links":[],"tags":[]},{"id":"15848371-46b7-4cba-8f4f-69dc2632d109","original_quiz_id":"6a81ee6fffd1c9a62188bbeb","created":"$D2026-08-16T17:27:52.578Z","description":"16. Con respecto al diagnóstico anterior, pesa 24 kg, cuál sería la dosis intravenosa inicial indicado para este paciente?","questionContent":"Dosis inicial en caso clínico","questionImage":null,"type":"single","options":[{"id":"A","text":"20 ml/kg en 15 minutos"},{"id":"B","text":"10 ml/kg en una hora"},{"id":"C","text":"5 ml/kg en 4 horas"},{"id":"D","text":"30 ml/kg en 30 minutos"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"10 ml/kg en una hora","helpful_links":[],"tags":[]},{"id":"7441264f-a472-46be-baf9-3c709187ba21","original_quiz_id":"6a81ee6fffd1c9a62188bbeb","created":"$D2026-08-16T17:27:52.578Z","description":"17. Mismo paciente tolera vía oral, se reporta por fiebre, qué medida sería la más adecuada?","questionContent":"Tratamiento ambulatorio de fiebre","questionImage":null,"type":"single","options":[{"id":"A","text":"a) Acetaminofen en tableta 500 mg VO c/8h"},{"id":"B","text":"b) Acetaminofen en jarabe concentración de 165ml, 5 ml, VO c/8h"},{"id":"C","text":"c) Acetaminofen en jarabe concentración de 165ml, 15 ml, VO c/6h"},{"id":"D","text":"d) Acetaminofen en jarabe concentración de 125ml, 15 ml, VO c/6h"}],"correctOptions":["C"],"matches":[],"match_pairs":[],"explanation":"c) Acetaminofen en jarabe concentración de 165ml, 15 ml, VO c/6h","helpful_links":[],"tags":[]},{"id":"c35fe36a-eac6-45e2-be9d-cf9566e883e9","original_quiz_id":"6a81ee6fffd1c9a62188bbeb","created":"$D2026-08-16T17:27:52.578Z","description":"20. Conociendo el mecanismo de la hemorragia por dengue pero es posible que el siguiente sea el factor determinante:","questionContent":"Mecanismo de hemorragia en dengue","questionImage":null,"type":"single","options":[{"id":"A","text":"Trombocitopenia y disfunción endotelial con aumento de permeabilidad vascular"},{"id":"B","text":"Deficiencia congénita de factor VIII"},{"id":"C","text":"Destrucción masiva de eritrocitos por hemólisis autoinmune"},{"id":"D","text":"Inhibición directa de la protrombina por proteínas virales"}],"correctOptions":["A"],"matches":[],"match_pairs":[],"explanation":"La trombocitopenia asociada a la disfunción y permeabilidad vascular es el factor determinante en las hemorragias por dengue.","helpful_links":[],"tags":[]}],"id":"6a81ee6fffd1c9a62188bbeb","name":"posibles preguntas pediatria 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posibles preguntas pediatria

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