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MANEJO DE CONVULSIONES EN EMERGENCIAS PEDIÁTRICAS — Transcript

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0:00Good morning to all participants. We
0:02extend a warm welcome from the Ministry
0:04of Health and the Directorate of
0:06Infosalud. Today we have this important
0:10presentation on the topic of seizure
0:12management in pediatric emergencies.
0:15This topic will be presented by Dr.
0:17Jordi Hidalgo Gamonal, who is a
0:20pediatrician at the National Institute
0:23of Children's Health. Thank you, Doctor
0:26, for being with us. Guests from the
0:29Directorate of Infosalud, before
0:31starting this important presentation,
0:33we are going to invite all participants
0:36to share the link so that more health
0:39professionals can be aware of this free
0:41teletraining for everyone. We are also
0:44going to share the attendance log in
0:47our chat, and remember that you can ask
0:50your questions through the Zoom chat
0:53and through our YouTube channel. We are
0:56going live on Telesalud Minsa,
0:58Teletraining. You can also leave your
1:00questions on the YouTube channel.
1:02Doctor Hidalgo, good morning. Thank you
1:04for being with us.
1:09How are you? Good morning. Thank you
1:10very much for the invitation and for
1:12being able to participate in this
1:13important talk.
1:15We are grateful to you for having you
1:18on our Infosalud channel and also
1:20grateful to the National Institute of
1:22Children's Health. We look forward to
1:25your excellent presentation.
1:27Thank you very much. Well, thank you
1:29again for the invitation. Let me start
1:32by saying that seizures in children are
1:36one of the most important reasons why
1:40children go to the emergency room.
1:44Right. Then, respiratory diseases,
1:47diarrheal diseases, and seizures are
1:52also important in important statistics.
1:57Much is mentioned and much is said
1:59about what to do when a child with a
2:02seizure arrives at the emergency room.
2:05In this regard, what we have to
2:07remember is the following: the
2:09objective of managing a seizure in a
2:11child who is in the middle of a
2:13neurological crisis, in the middle of a
2:16seizure, is to stabilize the patient.
2:19The most important thing to remember is
2:22to regulate vital functions and, in
2:25this way, control the neurological
2:28crisis immediately and quickly, because
2:32if this is prolonged and continues or
2:35the crisis is not aborted, the
2:37mortality rate increases up to 10 times
2:41. That is why it is important to
2:43recognize the crisis and abort it
2:46immediately, right? Always stabilizing
2:48the patient as a basic principle. For
2:52every minute of delay in managing the
2:56seizure, there is a 5%risk that the
3:00seizure will last more than an hour.
3:04The importance of aborting the seizure
3:06in a timely manner, always stabilizing
3:09the patient, is once again to emphasize
3:11. And for that, we use various
3:14medications, we use a lot of drugs,
3:17because at the time of the crisis, some
3:19of them will have to be prioritized in
3:22an order, which is what we are going to
3:25explain today. There is no sequence of
3:28medications to use when a patient with
3:31a seizure arrives. For example, we have
3:35drugs that you may already know, such
3:38as phenytoin, phenobarbital, densin,
3:41and a series of drugs that are used in
3:45different ways. Some are administered
3:48intravenously, others orally, and
3:50others nasally. There are different
3:52ways to administer it, but there is an
3:54order in which it must be used
3:56correctly, and that is what we are
3:58going to emphasize today. We cannot
4:01predict, no, we cannot say that this
4:04seizure that the child is having is
4:06going to end at this moment. Most
4:09seizures that children have have an end
4:12. There is a beginning, and it takes a
4:15few minutes of close attention for the
4:18parents and even for the doctor, but in
4:20most cases it ends. However, in some
4:23children, there is a small group of
4:25children whose seizures continue, they
4:27do not stop. We are probably facing a
4:30convulsive status. We cannot predict
4:32that this crisis, this seizure is going
4:35to end in a status. So, I understand
4:37that status refers to a seizure with a
4:39prolonged duration. Now we are going to
4:42explain some figures, some numbers.
4:44Therefore, the treatment sequence that
4:47we have mentioned will start precisely
4:49with drugs called first-line and little
4:52by little we will progress to
4:54second-line drugs, then third-line
4:57drugs, as the patient does not improve.
5:00Okay. So a patient arrives with a
5:03seizure, and I am sure that this crisis
5:05, this convulsion, will stop, and will
5:08not end in status. There is a small
5:12group of children whose seizures will
5:14probably not stop and will continue to
5:16convulse. So, we are facing status and
5:19for that we use first-line drugs in a
5:21certain order, second-line, third-line.
5:25This is what I was trying to explain to
5:27you at the beginning. The first 5
5:30minutes of the seizure, we can say that
5:33the patient is facing an initial state,
5:36it is starting, right? The first 5, 10
5:39minutes are known as the initial state.
5:42After 10 to 30 minutes that the seizure
5:46continues, we are facing an established
5:49state or established status. At this
5:52stage, there is already neurological
5:53damage, damage to neuronal tissue. When
5:56the convulsion lasts 30 to 60 minutes,
5:59we are already facing a refractory
6:02state; it is a refractory convulsive
6:04state and, obviously, this moment, this
6:07state, is very, very crucial, very,
6:10very important to be able to abort it
6:13now, because, despite the fact that
6:15certain medications such as pinas have
6:18been used, the patient continues to
6:21convulse and it is known as a
6:23superrefractory state, although it may
6:26seem incredible. The child is already
6:28convulsing for more than 24 hours, a
6:30whole day. There are cases in which the
6:34child convulses for more than a day, a
6:37superrefractory state. So, we are not
6:40going to wait for 30 minutes to arrive
6:42to say, "Oh, it is an established state
6:45." But from the first 5 minutes we have
6:48to remember that we are facing an
6:50initial state and we have to go about
6:52managing it in a correct way. So, let's
6:55understand that a seizure is not
6:58synonymous with epilepsy. Yeah. A
7:00seizure can be due to various causes,
7:03such as a medication, a sudden fever in
7:07a child, trauma, an infection. There
7:09are many causes that can provoke this
7:11neurological crisis or this seizure.
7:14Yeah, but when the seizure is chronic,
7:17the patient has many seizures
7:19throughout their life, we can even say
7:22that it is epilepsy as a disease. So,
7:25let's understand that a seizure is not
7:27synonymous with epilepsy. That is the
7:29first thing to remember. A seizure can
7:31happen to any child who suddenly has a
7:33high fever and this child starts to
7:36convulse and it is not necessarily
7:38going to be a child with epilepsy, okay
7:40? And most epilepsy as a disease does
7:43not always also have a seizure as a
7:46characteristic, that is, body movement.
7:49There are some forms of epilepsy in
7:50which they are very subtle and do not
7:52necessarily have these seizures. So,
7:54let's be very clear. So, when we have a
7:57seizure, that is, involuntary movement
8:00of the body with loss of consciousness,
8:02many times we have to try to remember
8:05that there are two main presentations.
8:07The first is the so-called generalized
8:09convolution. As you can see here in
8:11this image, you can see the brain with
8:14different foci in which there is
8:16neuronal hyperexcitation, right?
8:18Different foci that are connected,
8:20right? In an erratic way and that will
8:23ultimately cause the so-called
8:25generalized convulsion, that is, the
8:27entire body of the child convulses. But
8:30there are also so-called focal
8:32convulsions in which only one part, one
8:35extremity, the eye, the child's little
8:37leg, only one part begins to have
8:39involuntary movement. Okay? So in that
8:42case, only one focus is seen, as you
8:45can see here in the part of the brain
8:48that is hyperexcited. The most common
8:51thing we see in children who come to
8:53the emergency room are generalized
8:55convolutions, as we can see here.
8:57Initially, the child has a phase called
9:00tonic in which their body is very
9:02contracted. You can see here, you can
9:05see the little one in a state of
9:07hypercontraction, followed by a clonic
9:10phase in which there are involuntary
9:13body movements, right? So there is an
9:15initial tonic phase and a phase later
9:18called the clonic phase. Tonic phase,
9:20clonic phase. This is the most common
9:24convolution and it is a generalized
9:27type convolution, but children can also
9:30have convolutions in which only one
9:32extremity is moving, a part of their
9:35face, their lips, perhaps their little
9:38foot, these are focal convolutions.
9:41Well, in the end, either one involves
9:44hyperexcitation of neuronal tissue in a
9:47specific part of the brain, and it must
9:49be recognized and acted upon
9:51immediately. So, today's topic, right?
9:54What should I do? What should I do when
9:57my emergency occurs? My emergency room
9:59arrives, a little child arrives at my
10:01health service with these neurological
10:03crises. Well, the first thing you have
10:06to do is stay calm. That's the first
10:09thing to remember, and to do so, we
10:11have to remember certain time frames,
10:13since from the first minute zero to the
10:16first five minutes is a phase in which
10:18it is very likely that the seizure will
10:21stop on its own. Let's understand this.
10:24The first 5 minutes, also called the
10:27stabilization phase, it is very likely
10:31that the seizure will stop
10:33spontaneously. Okay. What should I do
10:36during these first 5 minutes? So, the
10:38first thing you have to do, as I said,
10:40is stay calm. Why? Because it is very
10:43likely that the seizure will stop, but
10:44I also have to support the patient, I
10:46have to help them. How? By protecting
10:48them, right? By placing the patient on
10:50their side in a position called lateral
10:53recumbency, right? To avoid trauma,
10:55that they could suddenly get injured,
10:57etc. Therefore, the physical protection
11:00of the patient is very important. Okay,
11:02what else should I do? I'm calm now,
11:05I'm protecting the patient, I put them
11:08on their side to avoid trauma or injury
11:11and now I have to worry about their
11:13airway being patent. Why? Because
11:16during the crisis the patient might not
11:19have a good airway, and that would
11:21cause problems, because when the airway
11:23is blocked or obstructed, it will
11:26prevent oxygen from reaching the brain
11:28and things will get worse, since the
11:30tissues of the human body, as we know,
11:33retain oxygen. For that reason, it is
11:36very important to have a patent airway
11:39in your brain in these first 5 minutes,
11:42which is the airway that has to be
11:45patent. How am I going to achieve that?
11:47asking for support from my nursing
11:50staff, my technical staff, please help
11:52with the aspiration of secretions. Look
11:54, there is a lot of salivary secretions
11:57in this little one. Let's aspirate him,
11:59let's place his head on one side. Okay.
12:02And if we consider that despite all the
12:05initial maneuvers we are doing, the
12:07little one, we see that no air is
12:09passing through, we see that the airway
12:12is not permeable, we could even
12:14consider endotrachial intubation,
12:16because we are managing the airway.
12:18Let's understand that the first thing
12:20to do is that, control, manage the
12:22airway. What else can I do? I have to
12:26provide adequate oxygen support during
12:28those first 5 minutes. I am calm now, I
12:32have protected the patient, his airway
12:34is permeable, now I have to give him a
12:36good supply of oxygen. As I told you,
12:39during a seizure there is not an
12:41adequate flow of oxygen and we have to
12:44support the child with oxygen using
12:46various devices that we have: from a
12:48simple binasal cannula, which will
12:51provide an adequate flow of oxygen, to
12:53a small mask, as you can see here in
12:56the image, a simple oxygen mask. We can
12:59also consider, as we said in severe
13:02cases, the use of endotracheal
13:04intubation, that is, supporting him
13:06with mechanical ventilation. So,
13:09conclusions: I maintain a patent airway
13:12and, of course, I also maintain
13:15adequate oxygenation with various
13:18devices, right? With a cannula, with a
13:21simple mask or a reservoir mask, right?
13:25Or in more extreme cases, mechanical
13:27ventilation. What else should I do? I
13:29should also consider taking certain
13:31tests, for example, like a blood gas
13:34test, right? Blood gas analysis will
13:38allow me to see the patient's
13:40oxygenation, to assess, for example,
13:43their skin color, their perception,
13:45right? To see if there are any
13:47movements in their chest, I will check
13:49their respiratory rate, I will also
13:52listen to their lungs, all of this is
13:54part of the basic assessment of their
13:56respiratory system. What else? We also
14:00have to carry out complete patient
14:02monitoring, that is, monitor their
14:05heart function, respiratory function, I
14:07will place a thermometer, I will place
14:10a blood pressure cuff, how is the
14:12oxygen saturation and all of this is
14:15part of the complete patient monitoring
14:18. Look at everything we have to do
14:21during the first 5 minutes and you, as
14:23the leader of this health facility who
14:26is in charge of it at this important
14:28moment, have to lead; you have to tell
14:30your team: "Let's stay calm, let's
14:32protect the patient." You help me keep
14:36the airway clear, you help me with
14:38oxygenation with this device, and you
14:41help me with cardiac monitoring. And
14:44also something very important, as you
14:47can see here in the figure, is to start
14:49making the airway clear. Doctor Jordi,
14:53why is it important to start placing an
14:55intravenous catheter? Because we don't
14:57know, as I said, when this crisis is
14:59going to end. It's very likely that it
15:01will stop before 5 minutes have passed,
15:03but what if the crisis continues?
15:06Therefore, we need to have a line ready
15:09to place intravenous medications,
15:12hydration, etc. That's why it's
15:14important to have a clear venous access
15:17point. That's very important, right?
15:19And for that, we have our nursing
15:22graduates who are very good at this
15:25aspect. What else? Now that we have a
15:30clear line, we can also get a basic
15:32analysis, right? A basic blood test,
15:35for example, a complete blood count,
15:38which may already have some
15:39electrolytes, since many seizures are
15:42due precisely to electrolyte
15:44alterations, right? With altered sodium
15:46, either in a large quantity or in a
15:48small quantity. They also asked how his
15:52coagulation profile is, how his glucose
15:54is, because it could also be that his
15:57glucose is low and this can also cause
15:59seizures. How is his creatinine? How is
16:03his calcium? How is his magnesium? How
16:05are his transaminases? They could even
16:08start dosing him with some convulsants.
16:10If the child takes anticonvulsants, we
16:13can check his levels. It is possible
16:16that the medications he regularly takes
16:19are low because the doses were not
16:22updated during his appointments. We can
16:30also go ahead and request toxicology
16:32tests, etc. In conclusion, depending on
16:34the hand that I am taking or requesting
16:36that an intravenous line be placed, we
16:38can also obtain a basic blood test,
16:39right? What else? Many times, children
16:43have seizures in the pediatric
16:45population due to elevated body
16:48temperature, that is, fever. So we have
16:51to manage the hyperthermia, if there is
16:53one. No, we manage the hyperthermia
16:55with physical means, such as an
16:57antipyretic. But also in this initial
16:59stage, the first 5 minutes, we have to
17:01manage the hyperthermia, the fever, if
17:03there is one. If there is one, we can
17:06check the sugar, as I said, by means of
17:09a blood test, but also in rapid ways
17:13such as test strips, a hemoglucotes
17:16that allow me to have a quick glucose
17:19value. No. Many children have seizures,
17:22many babies have seizures precisely
17:24when their glucose is low. And if we
17:27find, through a test strip, that is, a
17:29hemoglucotes in the finger, that the
17:32glucose is low, less than 60, less than
17:3550, we have to correct it immediately.
17:38And in this way we have the first 5
17:40minutes of the little one, which is
17:43called the stabilization phase. Some
17:47people do point 10. In some places,
17:50pyridoxine, which is vitamin B6, is
17:53used. They use it as a stage to
17:56administer pyridoxine in the initial
17:58stage. It is not used very frequently
18:00in these parts, but in some literature
18:03you will find that pyridoxine can be
18:05administered, since many causes of
18:07seizures are due precisely to a
18:09deficiency of this vitamin. But this is
18:11the general rule. As you can see, at no
18:13time have we given an anticonvulsant,
18:16an antiepileptic or anything. What have
18:19we done? The ABC of any emergency,
18:22right? Maintaining a patent airway. We
18:25have had adequate oxygenation and of
18:28course adequate monitoring of
18:30cabriorespiratory functions. This
18:33happens in the first 5 minutes. I have
18:35already stabilized the patient, I have
18:38him monitored. The question now is, of
18:40course, anticonvulsants are not used.
18:43The seizure continues, that is, the 5
18:45minutes have already passed. What
18:48happened with the seizure? Did the
18:49patient laugh during the seizure or
18:51does the seizure continue to convolute?
18:53There are only two options here. There
18:55is no more seizure. It aborted
18:57spontaneously, as expected, remember?
19:01It was very likely that the seizure
19:02would subside before 5 minutes. Well,
19:05if the seizure is over, there is no
19:07longer a convulsion, symptomatic
19:08treatment and all the corresponding
19:11management must be done, and the cause
19:13of the seizure must continue to be
19:15investigated. But what happens if the
19:17seizure persists, the seizure continues
19:20, and it has been more than 5 minutes?
19:22Then, in that case, we have to open
19:24another algorithm. If the seizure
19:27continues, what I have to do in these
19:29cases is the following, move on to the
19:32next phase. This next phase already
19:35understands that it is more than 5
19:37minutes. Don't forget that more than 5
19:41minutes is already an early convulsive
19:43status. Don't forget that more than 30
19:46minutes is an established convulsive
19:47status. Remember the first slides.
19:50Don't forget that more than 60 minutes
19:52of seizures are called refractory
19:54status convulsiveis and more than an
19:56hour of an entire day was called
19:58superrefractory status convulsiveis.
20:00These were terms that need to be
20:01addressed. Very good. So, more than 5
20:03minutes have passed, we are entering
20:06the next phase. It is precisely in this
20:09second phase in which I have between
20:11the times, if we want to be very
20:14precise, from minute 5 to minute 20.
20:17What are going to happen in these 15
20:19minutes that I have from minute 5 to
20:22minute 20? I am going to start giving
20:25medication. Now, yes, here I am giving
20:27medication. What medication am I going
20:29to use? Benenzodiazepines. Remember
20:33that benenzodiazepines are abortive
20:36drugs, they are going to abort the
20:38seizure. Since 5 minutes have already
20:40passed, the patient has stabilized, but
20:42the seizure continues. So, what do I
20:45have to do? Use benenzodiazepines. That
20:48is why they are called first-line drugs
20:50. What are the first-line drugs? They
20:54are the benensoria. Here I will mention
20:57a few. You can choose any of the
20:59following that I will mention. Okay.
21:02Here it goes. For example, I can use
21:04the famous mirasolan. Yes, it is a very
21:07good, widely used epinephrine. You can
21:10give it intramuscularly. IM stands for
21:13intramuscular. Here I am writing down
21:15the dose so that you can put it into
21:17practice. 0.2 mg per kilo is the dose
21:19that you are going to give your patient
21:22. Maximum dose 10 mg. Now, doctor, can
21:26I use another medication? Look, here I
21:28have a small ampoule of lorepan. Well,
21:31use it intravenously. And the dose is
21:340.1 mg per kilo. The maximum dose is 4
21:38mg. Doctor, I have Diepán at my health
21:41center. Use it intravenously, 02 mg per
21:45kilo dose, maximum dose 10. It is very
21:49important for you to remember these
21:53drugs, since they are effective
21:56anticonvulsants. They are
21:59abortifacients, but they will not treat
22:03a disease such as epilepsy. That must
22:05be understood. They are not
22:07antiepileptics, in short. They abort
22:10seizures. They are anticonvulsants, and
22:13precisely because of their rapid action
22:16, what they will do is abort the
22:18seizure, but they will not prevent
22:20another seizure. That is what I want to
22:23explain. Okay? So, in these 15 minutes
22:26that we are in the stage called the
22:28first phase of therapy, I am going to
22:31use benezodiazpines, midasolan or
22:33florazeepán or Diacán, whatever you
22:36have on hand. And these drugs are
22:39called first-line drugs and can be
22:41repeated, even the dose can be repeated
22:45once or even a second time, there is no
22:48problem. The important thing is to
22:50abort the crisis. Remember that we have
22:52been going for more than 5 minutes.
22:54Something very important is that if
22:57none of the three options are available
23:01, you can use midazolam intranasally.
23:04Yes, you can place midazolam in the
23:07ampoule in the nostrils, doctor. The
23:10dose is the same, 0.2-2 mg per kilo,
23:12but instead of placing it in the
23:14aforementioned routes, I can place it
23:17directly in the nostril, right?
23:19Interesting. Or you can use dipan
23:22rectally. Remember that the rectum has
23:25a lot of vascularization and the drug
23:27could be absorbed and abort the crisis,
23:30but if it is administered rectally, you
23:32have to give a little more than the
23:34dose, that is, 0.5 mg per kilo. Don't
23:37forget the maximum dose here, 20 mg
23:40rectally. In conclusion, sciadiazepines
23:43are very versatile in their
23:44administration method. We have all the
23:47routes, intravenous, intramuscular, and
23:51even nasal and rectal. Let's ask, 15
23:54minutes have already passed, that is,
23:58we are at minute 20, we have already
24:01completed the stage in which we used
24:05sciadiazepines a second time. I ask, is
24:09the seizure continuing? If the seizure
24:12was aborted, there is no longer a
24:14seizure thanks to one of the
24:15medications you prescribed, symptomatic
24:18treatment, we continue investigating
24:20what happened, etc., but the seizure
24:22has already passed, but the following
24:24may happen. The seizure continues, the
24:27seizure persists, the convulsion goes
24:30beyond the time you were expecting it
24:33to address. What should I do in these
24:35cases? Move on to the next phase. In
24:38other words, I am going to use other
24:40medications now. Why? Because I have
24:42already used sciadiazepines. Remember
24:43that the gisodespines that we are using
24:45are going to be used precisely in this
24:47stage called the first phase of therapy
24:50, which goes from minute 5 to minute 20
24:52, but there has been no improvement.
24:54For that reason, I am going to the next
24:55phase. In the next phase, I am going to
24:59use this group of medications. We are
25:03in the second phase of therapy, the
25:05second pharmacological phase, and I
25:07also have approximately 20 minutes,
25:10that is, from minute 20, remember that
25:12we stopped at minute 40. During these
25:1520 minutes, I am going to continue
25:17giving the patient medications, but now
25:20I am going to use second-line drugs.
25:23Let's review. First-line drugs were
25:26benezodiazine, miran, dicepan, etc.
25:29Here we are at minute 20 to minute 40
25:33of the seizure and we have to use
25:36second-line drugs. What are these drugs
25:40? Let's choose one of them. Let's
25:42understand that we only have one route
25:44of administration for these drugs, that
25:46is, I only have the intravenous route
25:48to be able to administer them. These
25:50drugs are not administered orally,
25:52nasally, or rectally. They can only be
25:55administered intravenously or even
25:56intramuscularly. Just imagine, doctor,
25:59what drug am I going to use at this
26:01stage? The very famous phenytoin.
26:05Phenytoin, and it is written down very
26:07clearly here, intravenously. I am going
26:10to use phenytoin at this stage. And
26:12here is the dose, 20 mg per kilo, right
26:16? A maximum dose of 1000 mg, or 1 g of
26:20the medication. Right. Phenytoin. So,
26:23it is the medication of choice in this
26:25second phase of therapy. Now, once you
26:28administer phenytoin, it is very likely
26:32that the seizure will subside, that the
26:35seizure will disappear and then we have
26:39to give the patient a dose of phenytoin
26:42, but this is for maintenance. This
26:45dose of 20 is the loading dose, a high
26:48dose, as you can see, 20 mg per kilo,
26:50right? But after 20 mg per kilo, we
26:53have to give a maintenance dose
26:55throughout the day. The dose ranges
26:58from 5 to 10 mg per kilo throughout the
27:01day. I can divide it every 8 hours,
27:04always intravenously. You can use 6, 7
27:07mg, 8. You can more or less choose the
27:10maintenance dose, but remember that the
27:13starting dose without fear is 20 mg per
27:16. Now, this phenytoin has some
27:20peculiarities, since it reaches a
27:22maximum peak of action after more or
27:24less 10 to 30 minutes, right? In other
27:27words, its maximum effect will be more
27:29or less reached, its maximum peak of
27:32action after 10 to 30 minutes, since
27:34its brain concentration is very high
27:36compared to the plasma concentration.
27:39Now, this phenytoin in the commercial
27:43part already has a compound, a
27:45preparation called propyl glycol. And
27:49this propylene glycol is the cause, it
27:52is responsible for many side effects.
27:55For example, they say, "I don't want to
27:57use phenytoin. I'm afraid because it
27:59can cause hypotension, it can cause
28:01arrhythmias, and it scares me a little.
28:03" Yes, that's true. It can cause
28:06hypotension, not always, but it can,
28:08but that's due to the content called
28:11propyl glycol, which is part of the
28:13compound. Right, doctor? And couldn't
28:15they sell us phenytoin without that
28:17preparation, that propyl glycol? In
28:19fact, they do sell it, but not here in
28:21our area, right? So just in case, I
28:23want you to know. There are already
28:26some preparations of phenytoin, of
28:28course, but they don't contain this
28:31propylene glycol. Oh, just in case, if
28:34the seizure persists despite you
28:37administering this initial bolus of 20
28:40mg per kilo, you can give a second
28:43bolus, but at 10 mg per kilo. In other
28:46words, you reduce the dose by half. As
28:48I repeat, the most common thing is that
28:51the first bolus of phenytoin subsides
28:54the seizure. And if it persists, you
28:57can administer a second bolus of 10 mg
29:00just in case, okay? In other words,
29:02half. Let's continue. This is the
29:04medication I was telling you about,
29:06it's called fosphenytoin. We don't sell
29:08it here, we don't have it here. But
29:10fosphenytoin is a prodrug that acts
29:14much faster than phenytoin, since it
29:18acts in 5 to 10 minutes and does not
29:21need this propylene glycol, since it
29:25can even be used intramuscularly. It
29:29would be very interesting to be able to
29:31obtain this drug, to be able to get it,
29:33but what we have in our reality is
29:35phenytoin, just in case. Let's continue
29:37. Uh, what else can I use? I can use
29:41intravenous valcroic acid. We don't
29:43have this preparation either, obviously
29:46, but I wanted to share this
29:48information that in other places there
29:50is intravenous valproic acid and if
29:53your health center has it, you can
29:55administer 40 mg per kilo or a maximum
29:58dose of 3 g, that is, 3,000 mg, right?
30:00Just in case. Doctor, can I use another
30:03drug? Well, if you have mild
30:05intravenous tiracitan, it is not easy
30:07to get this. You can use the dose of 60
30:10mg per kg. Maximum dose 5 g, right?
30:14That is, 5,000 mg. Of all these three
30:17medications that are second-line drugs,
30:20remember, the one we have available and
30:23easy to get is phenytoin in 90. Don't
30:26forget, 20 mg per kilo of attack and if
30:29there is no improvement, a second bolus
30:31of 10 mg per kilo. It is important to
30:36mention, very important, if phenytoin
30:40or the drugs mentioned here do not work
30:44, I can use the famous phenobarbital.
30:48Phenobarbital is also a widely used
30:50anticonvulsant, available in health
30:52centers. I can use it, yes, at the same
30:56dose as phenytoin, that is, 20 mg per
30:59kilo dose. There are even some patients
31:02who already have established epilepsy,
31:04such as Drave syndrome, for example, in
31:06whom I cannot use phenytoin because
31:08phenytoin, that type of seizure, that
31:11type of epilepsy, cannot be prescribed.
31:14Phenobarbital will have to be used
31:16immediately, right? So, at this stage,
31:20which is called the second phase of
31:22therapy, which goes from minute 20 to
31:25minute 40, I have to use second-line
31:27drugs that are administered
31:29intravenously; and the most important
31:32or best-known one that you have at this
31:34stage is phenytoin, at a dose of 20 mg
31:37per kilo and with a maintenance dose
31:40throughout the day of 5 to 10 mg
31:42distributed, they can be intravenously,
31:44every 8 hours. And if phenytoin has no
31:47effect, I can use phenobarbital at the
31:50same dose, 20 mg per kilo. I ask, what
31:54happened with the seizure? Have these
31:5740 minutes already passed? Is the
31:59seizure continuing? If the answer is no
32:02more seizures, no more convulsions, how
32:04good is asymptomatic treatment for the
32:07patient? Hospitalize them and do a
32:09study right away to see what happened,
32:11why has this patient been convulsing
32:13for all this time. But the following
32:16will probably happen, which is
32:18precisely today's topic, right? What
32:20happens if the seizure continues? I
32:22mean, it's been more than 40 minutes
32:24and the seizures continue. What do I do
32:26at that point? Well, in these cases,
32:29what you have to do is ask for it, make
32:32a referral, okay? Or in any case, also
32:35make a call to a pediatric ICU because
32:39much stricter monitoring is required
32:42for this patient who is in a delicate
32:45state. We've already been more than 40
32:48minutes. The seizure persists. I have
32:51already used the first-line medications
32:53, such as leflunomide, I have already
32:55used phenytoin, I have already used
32:57phenobarbital, a second-line drug, and
32:59the seizure does not improve; it
33:01persists. It is time to call it a
33:03pediatric ICU because the little one is
33:05going to have to move to this unit
33:07where the delicate patients are. So, we
33:11are looking at 40 to 60 minutes. During
33:16this time, I am going to use third-line
33:19drugs. We are in a very delicate stage
33:22of the patient, very delicate. And
33:25these third-line drugs are going to be
33:28administered, in small doses, but
33:31continuously, throughout the day,
33:34uninterruptedly. This way of
33:36administering the medication is no
33:38longer given in boluses or in large
33:40quantities, but in small doses, but
33:42throughout the day. It is called
33:45medication by infusion. Medication by
33:48infusion. And that is done precisely
33:51with the patient intubated, monitored
33:54in an intensive care unit. Okay? So,
33:57the third-line drugs that are going to
34:00be used in these patients with infusion
34:04pumps are already administered in a
34:07continuous manner. Okay? And if you add
34:10up each of the small doses that you are
34:12going to administer per minute, you
34:13will see that it is a very high dose of
34:15medication. That is why it is given in
34:17fractions. And in this intensive care
34:21unit, neurological monitoring with an
34:24electroencephalogram is very important.
34:28Why? Because it may be the case that
34:30the patient apparently no longer has
34:32seizures, but the electroencephalogram
34:36indicates that there is still
34:38paroxysmal activity in the brain,
34:40although the child does not have any
34:42obvious movement. Okay? So, in the ICU,
34:44the patient is receiving his medication
34:47infusion and, of course, strictly
34:50monitored with an electroencephalogram.
34:54Very good. What medication am I going
34:57to use to complete this stage? I am
35:01going to use diazepam. Here is the dose
35:05, look, from 0.2 to 1.2 mg per kilo per
35:08hour. As you can see, it is given at a
35:11rate throughout the day. I can also use
35:14myazolan, I can use midazolam at a dose
35:18of 1 to 16 micrograms per kilo per
35:21minute. These are the doses of the
35:23infusions. I can use sodium
35:26pentobarbital, another medication
35:28widely used in intensive care units. Uh
35:32, at a dose of 1 to 4 mg per kilo. Most
35:37other medications are preceded by an
35:39initial bolus, right? But then the
35:42infusion, that is, in the medication
35:45indicated per kilo per minute or per
35:47kilo per hour, is the key to giving it
35:50continuously at two high doses
35:53throughout the day. And of course,
35:56right? In some cases, some indicate the
35:58use of propofol, but in the case of
36:00small children, it is preferable not to
36:02use it yet, since there are no
36:04conclusive studies that can tell us
36:06that there is a proper safety range,
36:08which is why it is better to use
36:10propofol. So, as you can see, we are
36:13almost at 60 minutes of seizures. Hm.
36:16Minute 40, minute 60. We are already at
36:19the stage of using third-line drugs, we
36:21have already used benensesin in the
36:23first line, we have already used
36:26phenytoin, phenomarbital in the second
36:28line. Now we are on continuous infusion
36:31medication, we are using midasolan,
36:33pentobarbital, depending, and now comes
36:36another question, right? What happens
36:39with the seizure? It was aborted.
36:42Whether the seizure continues, or not,
36:45will depend precisely on the effect of
36:47the medication? Let's imagine that the
36:49seizure was aborted, there is no longer
36:51a seizure. Okay, we continue with the
36:53patient in the ICU, hospitalized,
36:55symptomatic management, determining the
36:57cause, continuing studies, in a few
36:58words. But what happens if the seizure
37:00continues? Doctor, we've been here for
37:03almost an hour and the patient is still
37:05convulsing. Of course, we have a
37:07serious problem here. What should I do?
37:10Don't forget that refractory status is
37:12considered when the patient has been
37:14convulsing for more than an hour, more
37:16than 60 minutes and we have used, as
37:18you can see, more than two drugs and we
37:20have used more than two medications.
37:23What should be done in these cases?
37:25Well, some recommend the use of
37:27isoflorane. Isoflorane is a medication
37:30that can reduce oxygen consumption and
37:32cerebral metabolism, right? Apart from
37:35increasing blood flow, it has low
37:37systemic toxicity and can be easily
37:39eliminated through the respiratory
37:42tract. These are studies that are still
37:45in the research phase, but there is
37:48promise with isoflorane; it will have
37:51to be applied to various populations in
37:54order to standardize its use. Others
37:58propose the use of anticonvulsants such
38:01as motrigine, vigabatrin, and felvamate
38:05, since they are still in the
38:07experimental phases for their use and
38:10in even untreatable cases, they do not
38:13stop the seizures. Some even opt for
38:17surgery, right? Lobectomies, etc.,
38:20right? But those are very extreme cases
38:23. So, as we have seen, seizures require
38:27very special management, right? From
38:30the first few minutes, which are the
38:32patient stabilization phase, in which I
38:35do not use medications yet, but I keep
38:37the patient stable: their airway,
38:39adequate oxygen support, and strict
38:41monitoring of vital functions. Then I
38:44move on to a stage in which I use
38:46first-line drugs, which are
38:48beneznodiazepines. Then I move on to
38:50second-line drugs, if there is no
38:52improvement, such as finito or
38:54phenobarbital. And then I move on to
38:56third-line drugs when I see that the
38:59patient is not improving using
39:01infusions of, for example, midasolan,
39:03or pentobarbital. But in the case of
39:07the pediatric population, there is a
39:09very special, very particular form of
39:11convulsion that is very frequent in
39:13emergency services. And I wanted to
39:16share with you in these minutes, as the
39:19presentation is almost over, which is
39:21the famous febrile convulsion, and with
39:24that we are concluding, since it is a
39:27very frequent reason to go to the
39:29emergency room. The father arrives with
39:31his little one in his arms, having a
39:33convulsion, a healthy little boy, by
39:35the way, but it catches our attention
39:37that the little one is super hot and
39:39the temperature on the thermometer
39:40clearly says more than 38. So, a
39:42febrile convulsion. Okay? So, what
39:45should be done? This algorithm is very
39:46simple, very practical. If it is a
39:49small child, a young child between 6
39:51months of age and 5 or 6 years of age,
39:54um, that is the most common age range,
39:57with a healthy brain (that is, without
39:59any underlying neurological disease), a
40:02fever of over 38, this is the first
40:05seizure that the child presents and it
40:07is characteristic of tonic clonic. As I
40:10explained, at the beginning, the tonic
40:12chord makes the body stiff, right?
40:14rigid. Then comes the phase of
40:16movements, the clonic phase and the
40:18whole body does it. It is a generalized
40:21tonic convulsion. There is a
40:23characteristic ocular reversion; the
40:25little eyes are rolled back. There is
40:28even relaxation of the sphincters, that
40:31is, the child defecates, and it lasts
40:34less than 15 minutes, after which the
40:36patient is recovered; that is, he is
40:39awake, a little drowsy, but he is awake
40:42. That is, there is a post-ict recovery
40:45, that is, after the seizure there is a
40:48recovery, the patient is awake again if
40:51they meet, they meet all these
40:53characteristics. I repeat, age range
40:57between 6 months and 5 or 6 years,
41:00healthy brain, fever over 38 grams.
41:04First episode, first seizure. Remember,
41:07generalized tonic clonic, the whole
41:10body with backward reversion of the
41:12eyes, finter relaxations, it lasts less
41:15than 15 minutes and the patient is
41:18recovered, there is a post-ict recovery
41:21compared to a simple febrile seizure.
41:25All the characteristics that I just
41:26mentioned are of a simple febrile
41:28convulsion and that has, believe it or
41:30not, a good prognosis, that is, it is
41:32not something serious or bad, it can
41:33happen to any of the little children,
41:35our children. Hey, what do I have to do
41:38? Lower the fever, obviously, and look
41:41for the source of infection, right? The
41:43most common is pharyngitis, a urinary
41:45tract infection, or something that is
41:47causing the fever. I observe the
41:50patient and something very important is
41:52to explain to the father, right?
41:54Explain to the father that there are no
41:56major neurological repercussions,
41:57because the first thing the father
41:59thinks is that his child is going to
42:01have epilepsy, that he is going to have
42:03new episodes later on, which does not
42:05always happen. Okay? So, let's
42:07understand that this can happen to
42:08anyone. There are some predictive
42:10populations that could be more
42:12predisposed than others, but this one
42:15in general does not have a bad
42:17prognosis, simple and when it meets the
42:19characteristics that we have mentioned
42:21here. Okay. Now, what happens if it
42:24does not meet those characteristics? In
42:26other words, the child, for example, is
42:28, let's say 8 years old. He already has
42:30an underlying brain disease. The fever
42:33suddenly came on and did not reach 38,
42:36it reached 37.7, for example. There are
42:39several seizures, right? There are
42:41several seizures, it was not just one,
42:42there were several, right? Uh, it
42:45wasn't tonic-clonic, it was just part
42:48of his arm or it suddenly lasted 20, 30
42:50, 40 minutes and he still hasn't
42:53recovered from the seizure. So, this is
42:55not a simple febrile seizure, it is a
42:58complex febrile seizure. If it doesn't
43:01meet the aforementioned characteristics
43:03, it is a complex seizure and with
43:05these complex seizures it is
43:07recommended that the patient be
43:08hospitalized in a ward so that we can
43:12see what has happened. Okay? So, when a
43:15child arrives with a febrile convulsion
43:18, the first thing to do is
43:19differentiate. Is it a simple or a
43:21complex one? Here are the
43:23aforementioned characteristics. Very
43:25good. Now, uh, what should I do? An
43:28initial evaluation is always
43:31recommended, right? Using the pediatric
43:34assessment triangle, if I have a child
43:36with a poor appearance, abnormal
43:38respiratory work, or normal skin
43:40circulation in the context of a febrile
43:43seizure, this is a child who needs to
43:45be taken immediately to the trauma room
43:48for stabilization. This is important at
43:51that time. If there is a fever, lower
43:54it, as we mentioned, right? With
43:56physical means, an antipyretic
43:57depending on the severity of the
43:59condition, and remember that not all
44:00juvenile seizures require
44:01hospitalization. Most of them should be
44:04hospitalized, but it will be considered
44:07. If this is the case, a simple febrile
44:10seizure, do not forget to advise the
44:13parents, explain it to them, reassure
44:16them and control the fever by giving
44:18paracetamol or another antipyretic,
44:21right? This, initially on an hourly
44:23basis, right? The dose is already
44:25mentioned here, 15 mg per kilodose, and
44:28then conditionally, and do not forget
44:30to go to a pediatric neurologist's
44:32office, right? Or pediatrics in general
44:34, ideally a pediatric neurologist. And
44:37of course, there are specific warning
44:39signs that would make you go to the
44:41health center. And if it is a complex
44:44febrile seizure, explain to the father
44:46the need to probably hospitalize him
44:48for further studies. Very good. So, do
44:51not forget that this type of seizure is
44:54very common in the pediatric population
44:57and you have to differentiate it from a
44:59simple febrile seizure or a complex
45:02febrile seizure and above all know if
45:04this child is going to stop the seizure
45:07or if it is going to continue. It will
45:10continue as not seen in the initial
45:12scheme and will end in a convulsive
45:13status where you would have to use, do
45:15you remember? all the stages mentioned.
45:18So, this is the summary of what we have
45:21to do when a patient arrives convulsing
45:24and is unstable. Three things must be
45:27done as mentioned. The summary is this:
45:29unstable patient convulsing, oxygen.
45:33Oxygen supply is important, airway is
45:35open and oxygen is available. Second,
45:39intravenous line. I can't know at what
45:41point the accumulation is going to stop
45:42. I have to have his endomenos ready to
45:45administer the appropriate endomenos
45:48medication and of course the monitoring
45:51of vital functions, strict cardiac
45:54monitoring with electrodes in the chest
45:57region, with his blood pressure cuff
46:00and of course with his sakuromio. And
46:03all this that is here is done in a
46:04coordinated manner as a team. Now, as a
46:07leader or as the person in charge at
46:09that moment of the emergency, you have
46:12to ask your team for help. Please,
46:14young technician, please help me. Let's
46:17place the patient in the bed, let's
46:20protect his airway, let's give him
46:23oxygen. Come on, help me, please, with
46:26venous access, please, you help me with
46:28cardiac monitoring and always calming
46:31your team. The accumulation will stop.
46:33And look, indeed most of the time we
46:35said the seizure subsides, the 5
46:37minutes have not passed and the seizure
46:40occurred spontaneously. And what are we
46:43going to do if the seizure continues?
46:44We have already explained first-line
46:46drugs such as espinal. Time passes, no
46:49improvement, I move on to a second-line
46:52drug such as phenytoin. Minutes pass,
46:54no improvement, I move on to a
46:56third-line drug; I call the ICU or make
46:59a referral, for your patient is still
47:01convulsing and...That is the way you
47:03have to work with your team, always in
47:05a coordinated manner, so that the
47:08functions that each one performs are
47:10optimal and efficient. I think this is
47:12the last slide. Finally, here are some
47:16recommendations, of course, it is
47:19important to identify the factor, that
47:23is, the cause of the event, that is,
47:26what precipitated this crisis? What
47:28caused the seizure? Was it an infection
47:31of the nervous system? Was it the high
47:33temperature? Was it a blow? Was it a
47:36sudden germ? Hm. Was it perhaps the
47:39onset of an epileptic disease? That's
47:42very important, but obviously that's
47:44done throughout the entire management
47:46process. In other words, at the
47:47beginning, you're not going to be
47:48thinking about what happened. No, at
47:50the beginning, you have to help the
47:52patient by stabilizing them. Hm. But
47:54throughout your entire assessment,
47:56you're asking yourself what happened.
48:00For that reason, it's very important to
48:03do a clinical assessment, a brief but
48:05complete medical history of the patient
48:08, a medical history aimed at finding
48:11what triggered it. Hm. Don't forget the
48:14infectious cause. It could be the fever
48:16itself, trauma, an idiopathic cause,
48:19but the assessment and identification
48:22of the factor that triggered the crisis
48:25are very important. What else? You also
48:30have to rule out these factors, as
48:32we've said, right? For example, trauma
48:34is a factor. There, you can also think
48:37about taking an image. Maybe it was
48:39because they fell out of bed, or
48:41because they fell from the first floor.
48:44So, at that time we have to ask for
48:46perhaps a neuroimaging, a CT scan, etc.
48:49, to be able to visualize, right?,it
48:51will be the bleeding that is causing
48:53this irritation of the nervous tissue
48:55and rule out if there is an infection.
48:58Virus, a bacteria, an amoeba, a prion?
49:02I don't know, what is causing this
49:04infection, this seizure. Was it a drug,
49:07a medication, an unknown substance that
49:10caused the seizure? A metabolic
49:12disorder, a sudden lack of glucose, an
49:15alteration in sodium, an alteration in
49:17calcium, AI or creatinine, suddenly
49:20very high AI? Hm. So, depending on the
49:23determination of what has caused it, we
49:26will also manage and control the crisis
49:28. For that reason, the neurological
49:31examination must include precisely the
49:33evaluation if there are no signs of
49:34intracranial hypertension. Now, this
49:37intracranial hypertension could even be
49:40due to trauma, focal alterations,
49:42evaluating the pupils, right? Always
49:45perform an adequate Glucose Scale,
49:48monitor Glucose levels frequently, and
49:51of course, if there is established
49:53endocrine hypertension, management with
49:56a component such as mannitol, right? If
49:59we suspect that there is cerebral edema
50:01, which is causing intracranial
50:04hypertension, the use of mannitol
50:06should be considered, right? And
50:08anti-edema treatment to lower the
50:10exchange pressure, right? These are
50:12recommendations that you should always
50:14take into account in a patient who
50:16comes to the emergency room with
50:18seizures. Okay, that would be all.
50:20Thank you very much for paying
50:21attention to the presentation and being
50:24very willing to answer any questions
50:26that you consider necessary. Thank you
50:28very much. Thank you very much, Dr.
50:30Hidalgo, for this excellent and
50:32important presentation. At this moment,
50:35we are going to read the questions that
50:37have been left for us both in the Zoom
50:40chat and on our YouTube channel. One of
50:42the questions, Doctor, well, apart from
50:45congratulating you on this excellent
50:47presentation, is, "Can I only use
50:49phenytoin or phenobarbital? Can I use
50:52both?" That's the question. Well, this
50:55is important depending on what your
50:58health center has, for example. And
51:01it's true, if we're going to use
51:02phenytoin or phenobarbital, and
51:04remember that we're already in the
51:06stage, the second phase of therapy,
51:08that is, between minutes 20 and 40,
51:12it's recommended to start with
51:14phenytoin, that's what the
51:17recommendations give us. Yes, the dose
51:20is 20 mg per kilo. But if I see that
51:24the seizure doesn't improve, it doesn't
51:26improve, I can repeat the phenytoin
51:29because we already have a permeable
51:31endomenal pathway and I can give a
51:33second bolus of phenytoin at 10 mg per
51:35kilo, that is, half. Most likely, the
51:39seizure will subside, but it could be
51:41the case that even though I have
51:42already used the first bolus of
51:44phenytoin or the second bolus of
51:46phenytoin halfway through, the seizure
51:48persists. I could use phenobarbital,
51:50that is, using phenobarbital, in short,
51:53is not recommended at first. If we have
51:56phenytoin on hand, great, unless it is
51:59an already established epilepsy in
52:01which the father himself even knows: "
52:04Don't give him phenytoin because it is
52:07an inito with no DR", for example,
52:09which is a very special epilepsy with
52:12neurological disorder, psychomotor
52:14impairment, etc., in which I know that
52:17I should not use phenytoin. Can I use
52:20phenytoin, of course, right? But more
52:22or less it is phenytoin first and if
52:25not, it is more likely, but the most
52:28common thing is that we can use
52:31phenobarbital afterwards. That is the
52:34answer.
52:35Thank you very much, doctor, for the
52:37answer. Pablo Ramos Martínez indicates
52:40, well, he thanks you for this
52:43presentation and makes some
52:45recommendations on the treatment and
52:47intervention for pediatric epileptic
52:50syndromes such as OTARA, W and Lenox
52:53syndrome. Greetings, doctor and teacher
52:56, he indicates. Good, Pablo. Of course,
52:59of course to Dr. Pablo Ramos, a great
53:01doctor. Well, in these cases, epileptic
53:07syndromes are entities in which the
53:10patient, the child, can already be
53:13recognized from very early stages of
53:16their age, right? Little ones who have,
53:20for example, certain characteristics
53:22such as hypotonia, there is no
53:24progression in their growth,
53:26development, even the neurological part
53:29progressively deteriorates and seizures
53:31occur very early. In these cases, the
53:34medication will depend precisely on the
53:37epileptic syndrome. We are talking
53:40about children who already have, as a
53:42diagnosis, epilepsy already established
53:44; The electrocephalogram has already
53:46been done, and we now have a clearer
53:48diagnosis, and in them, there are a
53:49series of recommendations for
53:51antiepileptic drugs that are very
53:53different from what is mentioned today,
53:55which they have to take. What's more,
53:57sometimes they use two, three, or even
54:00more antiepileptic drugs so that the
54:03patient can have, so to speak, a
54:05peaceful life. Right? Uh, unlike these
54:08patients that we have mentioned in
54:10today's interview, who are young, who
54:13have a normal neurological life and
54:15have had a seizure for the first time
54:17due to a cause that is not necessarily
54:20epileptic, as we have said, a trauma,
54:22an infection, fever and suddenly due to
54:25a metabolic disorder in which the
54:27seizure is treated, this seizure is
54:29aborted, the underlying cause is
54:31corrected and it is over. He never had
54:34epilepsy, he will only remember it as
54:36an episode of seizure that he had. But
54:38in other pediatric epileptic syndromes,
54:41such as lenogastric syndrome and a
54:43series of diseases such as epilepsy,
54:46the management is separate,
54:48multidisciplinary, requiring strict
54:50pediatric neurology evaluation; it
54:52requires the use of antiepileptic drugs
54:55, two or even three in combination, so
54:58that the patient has, so to speak, a
55:00life free of seizures. Something very
55:03important: when these children with
55:06established epileptic syndromes become
55:08unbalanced, that is, they get an
55:10infection, suddenly do not take their
55:12medication properly or have grown up
55:14and have not taken the dose, or rather
55:17have not calculated the dose properly,
55:19they could also end up in the emergency
55:21room with a convulsive status,
55:23precisely; but in that case we would
55:25call it status epilepticus because
55:28there is already underlying epilepsy.
55:30So, those are the recommendations that
55:32I can give to Dr. Pablo. Greetings
55:34again. Thank you very much, Pablito.
55:37Thank you very much, doctor, for your
55:39kind response. Paulo Gabriel asks us, "
55:42How long after the first bolus of
55:45phenytoin can I give the second bolus?"
55:50Well, regarding phenytoin, as I
55:53mentioned, its peak of action, right?
55:56Its peak of action. In other words,
55:58what I ideally expect is for it to have
56:00already had an effect after 10 minutes.
56:03We are talking about a strong bolus of
56:0520 mg per kilo of poison. So, more or
56:07less 10 minutes have passed and I can
56:09see that the seizure has indeed
56:10occurred. Let's remember that the peak
56:12is more or less between 10 to 20, 30
56:14minutes. But if I see that time has
56:17passed, more or less 30 minutes have
56:20passed and the seizure is not improving
56:23, I could in any case give the second
56:25bolus, but halfway through. We are not
56:28going to wait 30 minutes either, right?
56:30In practical terms, for example, if the
56:32first bolus of finito has not improved
56:35for 10 to 15 minutes, we can start the
56:37second bolus, that is, halfway through
56:39at 10 mg per kilo. And I repeat, it is
56:42very likely that the second bolus will
56:44stop halfway through, but we must start
56:48preparing our renewing tablets, just in
56:50case, so that they are on hand; because
56:52there is a small group of patients in
56:54whom this second bolus will not be
56:56effective either. We must have our
56:59verbals ready, just in case the seizure
57:01persists longer than necessary.
57:07Thank you, doctor. They indicate the
57:10first thing that should be done when we
57:13have a patient at school in an
57:15emergency situation.
57:19Okay, here we are talking about an
57:21extra-hospital setting. What should I
57:24do when I am not in a health center? I
57:27am suddenly at home, I am, uh, at
57:30school, suddenly, uh, nest. The first
57:35step, as a healthcare professional, is
57:39to always stay calm. What you should do
57:49is avoid using incorrect techniques,
57:50for example, such as placing objects in
57:53the mouth or, even worse, our anxiety
57:54and eagerness to help, we want to grab
57:56the patient, hold them tightly so they
57:58don't push, which is incorrect. In the
58:01hospital setting, staying calm and
58:03protecting the patient is very useful.
58:05Placing them in a protected position, a
58:07lateral position on their side, is a
58:10good idea because the patient could
58:13vomit and the secretions they are
58:15accumulating, because their digestive
58:18and respiratory systems are obviously
58:20not working well at that moment, could
58:23cause obstruction. So, the lateral
58:26position will help a lot to avoid
58:28injury and trauma, and to make sure
58:31their airway is open at that moment. If
58:34there is a tie that is tightening and
58:36you start to adjust it, suddenly there
58:38is a, uh, a piece of clothing at that
58:40moment that is very tight and is
58:42pulling the jacket out, right? Make the
58:45patient comfortable, in short, always
58:47on their side and of course ask for
58:49help, right? And understand, I repeat,
58:51the seizure will stop, the convulsion
58:54will subside, do not despair. And you
58:57will see that in most cases, not even 5
59:00minutes have passed and the convulsion
59:02is seen. The convulsion spontaneously
59:06disappeared. Then after that period,
59:08you have to help the patient, give them
59:09comfort, explain to them, right? Look,
59:11convulsed. He will probably tell you, "
59:14Well, if I suffer from such and such
59:17epileptic syndrome, I didn't take my
59:20medication in the morning, etc., but
59:22the patient recovers, recovers." That
59:25is what must be done in any case in the
59:27out-of-hospital setting, right? The
59:28first thing to do is to remain calm,
59:31support the patient so that they are in
59:33a protective position on their side. It
59:36is very important not to interrupt the
59:38seizure, not to avoid hugging the
59:42patient too hard, but to ensure that
59:44the seizure continues, always
59:46monitoring, protecting them and, of
59:49course, ensuring that there is good
59:51airway clearance so that air can pass
59:54naturally. Those are the
59:56recommendations made in the
59:57out-of-hospital setting. Thank you very
59:59much, doctor. We thank all the
1:00:02participants for leaving their
1:00:04questions. Our gratitude to you, doctor
1:00:07, for this excellent presentation. We
1:00:10hope to have you here again to train us
1:00:13on more important topics related to
1:00:16pediatric emergencies, right? To our
1:00:18Children. We would also like to thank
1:00:21the Telehealth Unit of the National
1:00:23Institute of Children's Health of the
1:00:25Ministry of Health for organizing this
1:00:27presentation in coordination with the
1:00:30Infosalud management. Thank you all.
1:00:32Remember that you can watch this
1:00:35training again on our YouTube channel
1:00:37Telesalud Mins Teletraining. Subscribe
1:00:40and share these free educational
1:00:42sessions with more health professionals
1:00:45. Thank you very much, doctor. Have a
1:00:47nice day, as did the participants.
1:00:49Thank you. Until another opportunity.
1:00:52Thank you.

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