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Adrenaline (Epinephrine) — Complete Emergency Drug Reference

Epinephrine 1:1000 (1 mg/mL) ampoule — the standard formulation used for anaphylaxis

1. What Is Adrenaline?

Adrenaline (epinephrine) is an endogenous catecholamine synthesized by the adrenal medulla. In emergencies it is administered exogenously as a synthetic racemic preparation. It is the single most important drug in emergency medicine, with roles in:

Anaphylaxis (first-line, only life-saving treatment)
Cardiac arrest (ACLS/PALS — only vasopressor recommended)
Symptomatic bradycardia refractory to atropine
Septic/cardiogenic shock (vasopressor infusion)
Severe bronchospasm

2. Mechanism of Action

Adrenaline is a non-selective adrenergic agonist, stimulating α₁, α₂, β₁, and β₂ receptors. The clinical effects follow directly from receptor pharmacology.

α₁-Adrenergic Effects (vasoconstriction)

Effect	Clinical benefit
Peripheral vasoconstriction ↑ SVR	Raises blood pressure; reverses vasodilatory shock
Coronary and cerebral vasoconstriction (high dose)	Directs blood to core during CPR
Mucosal vasoconstriction	Reduces angioedema / laryngeal swelling

α₂-Adrenergic Effects

Pre-synaptic feedback inhibition of noradrenaline release (minor clinical relevance at therapeutic doses)

β₁-Adrenergic Effects (cardiac stimulation)

Effect	Clinical benefit
Positive inotropy (↑ force of contraction)	Raises cardiac output
Positive chronotropy (↑ heart rate)	Increases minute output
Positive dromotropy (↑ AV conduction)	Useful in bradycardia/heart block
Increased automaticity	Can restore rhythm in asystole/PEA

β₂-Adrenergic Effects (bronchodilation + metabolic)

Effect	Clinical benefit
Bronchial smooth muscle relaxation	Reverses bronchoconstriction
Inhibits mast cell degranulation	Stops ongoing mediator release in anaphylaxis
Glycogenolysis, lipolysis	Metabolic stress response
Vasodilation (skeletal muscle)	At low doses, mild BP decrease

Cellular Signal Transduction (β-receptor pathway)

β-adrenergic signaling cascade: receptor → Gs protein → adenylyl cyclase → cAMP → PKA → calcium handling → increased rate of contraction, peak force, and rate of relaxation — Harrison's Principles of Internal Medicine

The β-receptor couples to a Gs protein → activates adenylyl cyclase → generates cAMP → activates Protein Kinase A (PKA) → phosphorylates:

L-type Ca²⁺ channels → increased Ca²⁺ influx
Ryanodine receptors on the sarcoplasmic reticulum → increased Ca²⁺ release
Troponin I → accelerates calcium dissociation (faster relaxation)
Phospholamban → enhances SR calcium re-uptake
Myosin ATPase → more ATP hydrolysis → faster cross-bridge cycling

Net result: increased rate of contraction, peak force, and rate of relaxation (lusitropy).

"The α-adrenergic action (vasoconstriction) increases SVR and PVR. The resultant higher aortic diastolic blood pressure improves coronary perfusion pressure and myocardial blood flow... Epinephrine also increases cerebral blood flow during good-quality CPR because peripheral vasoconstriction directs more flow to the cerebral circulation." — Miller's Anesthesia, 10e

3. Pharmacokinetics

Parameter	Detail
Onset (IV)	1–2 minutes
Onset (IM)	3–8 minutes
Half-life	~2–3 minutes (rapidly metabolized by COMT and MAO)
Metabolism	Liver, kidney, plasma — methylation (COMT) + oxidative deamination (MAO)
Excretion	Renal (as inactive metabolites: metanephrine, VMA)
Stability	Inactivated by alkaline solutions — never mix with sodium bicarbonate

4. Clinical Indications, Criteria, and Protocols

A. ANAPHYLAXIS

Diagnostic Criteria (Table 14-1, Tintinalli's Emergency Medicine)

Anaphylaxis is highly likely when ANY ONE of the following three criteria is met:

Criterion 1: Acute onset of illness (minutes to hours) with skin or mucosal involvement (urticaria, flushing, generalised itching, lip/tongue/uvula edema) AND at least one of:

Respiratory distress or hypoxia
Hypotension or cardiovascular collapse
Associated organ dysfunction (hypotonia, syncope, incontinence)

Criterion 2: Two or more of the following occurring minutes to hours after allergen exposure:

Skin and/or mucosal involvement
Respiratory compromise
Hypotension or associated symptoms
Persistent GI cramps or vomiting

Criterion 3: Hypotension after exposure to a known allergen for that patient (even without skin signs)

Common Triggers

Drugs (β-lactams, NSAIDs, vancomycin), foods (nuts, shellfish, eggs), insect stings, latex, contrast media, blood products.

Clinical Features by System

System	Signs/Symptoms	Incidence
Skin	Urticaria, angioedema, flushing, pruritus	60–90%
Respiratory	Wheezing, laryngeal edema, stridor, rhinitis	45–60%
ENT	Throat fullness, tongue swelling, uvular edema	50%
Cardiovascular	Hypotension, chest pain	30–35%
GI	Nausea, vomiting, cramps, diarrhea	25–30%
Neuro	Headache, seizure	5–8%

Anaphylaxis Treatment Protocol

Step 1 — Immediate Assessment (ABC)

Airway: examine for angioedema, stridor → intubate early if airway threatened (do not delay — progressive edema can make intubation impossible)
Breathing: SpO₂ monitoring, O₂ to maintain saturation >90%
Circulation: IV access, cardiac monitor, BP

Step 2 — Decontamination

Stop the offending agent if identifiable (stop drug infusion, remove stinger)
Do NOT perform gastric lavage for food allergens

Step 3 — EPINEPHRINE (FIRST-LINE — given immediately)

"Epinephrine is the first-line, most effective treatment for anaphylaxis." — Tintinalli's EM

Route	Dose	Concentration	Notes
IM (preferred)	0.3–0.5 mg (adult)	1:1000 (1 mg/mL)	Anterolateral thigh — fastest absorption
IM (child)	0.01 mg/kg (max 0.5 mg)	1:1000
Autoinjector (EpiPen)	0.3 mg adult / 0.15 mg child	1:1000
IV (severe/arrest)	0.1–0.5 mg bolus	1:10,000 (0.1 mg/mL)	Only in cardiovascular collapse with IV access
IV infusion	1 mg in 500 mL NS; start 2–10 mcg/min	Titrate to BP

Repeat IM dose every 5–15 minutes if no response
IM into the anterolateral thigh gives faster and more reliable absorption than deltoid or subcutaneous routes

Why does epinephrine work in anaphylaxis?

α₁: Constricts blood vessels → reverses hypotension and reduces mucosal edema/angioedema
β₁: Positive inotropy/chronotropy → supports cardiac output
β₂: Bronchodilation → reverses bronchoconstriction; also inhibits mast cell degranulation → stops further mediator release

Step 4 — IV Fluids

Bolus 1–2 L NS (or LR) rapidly for hypotension
Massive fluid shifts occur due to increased vascular permeability

Step 5 — Second-Line Agents (adjuncts only — do NOT replace epinephrine)

Drug	Dose	Role
Diphenhydramine (H₁ blocker)	25–50 mg IV/IM	Reduces urticaria/pruritus; does NOT treat hypotension or respiratory compromise
Ranitidine/famotidine (H₂ blocker)	50 mg IV	H₂ blockade complements H₁
Methylprednisolone	125 mg IV	Prevents biphasic reaction; onset delayed 4–6 h
Salbutamol (nebulised)	2.5–5 mg	Persistent bronchospasm after epinephrine
Glucagon	1–2 mg IV	Critical in β-blocker patients who are resistant to epinephrine's β effects

Special Consideration — β-Blockers: Patients on β-blockers may have blunted response to epinephrine. Give glucagon 1–2 mg IV as it bypasses adrenergic receptors and directly activates adenylyl cyclase. Consider atropine for bradycardia. Switch β-blocker to another class at discharge.

Biphasic Reaction Risk:

Occurs 3–11 hours after initial episode in 1–20% of patients
Observe all anaphylaxis patients for minimum 4–6 hours (8–12 hours if severe)
Discharge with prescription for ≥2 epinephrine autoinjectors, antihistamines (5 days), prednisolone (40–60 mg/day for 3–5 days), and allergy referral

B. CARDIAC ARREST

Indications

Ventricular fibrillation (VF) or pulseless VT — unresponsive to initial shock
Asystole
Pulseless electrical activity (PEA)
Profoundly symptomatic bradycardia (when atropine fails)

Mechanism in Cardiac Arrest

"Epinephrine may provide the most benefit within the first 15 to 20 minutes of cardiac arrest during the circulatory phase, based on its alpha effects of increasing peripheral vasoconstriction and coronary and cerebral blood flow." — Tintinalli's EM

α₁ vasoconstriction raises aortic diastolic pressure → increases coronary perfusion pressure (CPP) → critical determinant of ROSC
β₁ stimulation increases automaticity and contractile force if any cardiac activity present
Adverse: May worsen myocardial ischemia, increase O₂ demand, induce ventricular ectopy, and cause cerebral vasoconstriction (worsening neurologic outcomes especially after 20 min)

Cardiac Arrest Protocol (Adult — ACLS)

Timing	Action
0 min	Collapse → CPR (30:2 compressions:ventilations)
ASAP	Defibrillate if shockable rhythm (VF/pVT)
After 2nd shock / PEA/Asystole	Epinephrine 1 mg IV/IO
Every 3–5 min	Repeat epinephrine 1 mg IV/IO (no maximum number of doses)
Persistent VF/pVT	Add amiodarone 300 mg IV bolus after 3rd shock
ROSC achieved	Post-resuscitation care

Dose (Adult Cardiac Arrest):

Standard: 1 mg (1:10,000 concentration = 10 mL) IV or IO
Flush with ≥20 mL NS and elevate limb after each peripheral IV dose
Repeat every 3–5 minutes
High-dose epinephrine (2–5 mg) — no benefit over standard dose in survival; not recommended

Pediatric Cardiac Arrest:

Dose: 0.01 mg/kg IV/IO (1:10,000), max 1 mg per dose
Repeat every 3–5 minutes
Evidence for early administration in non-shockable arrest: may not be effective if given >15 minutes after EMS arrival

Route Preference: IV > IO > Central venous. The endotracheal route is no longer recommended (unreliable absorption due to pulmonary edema).

C. BRADYCARDIA (Non-Arrest)

Indication: Haemodynamically unstable bradycardia (hypotension, altered consciousness, chest pain, pulmonary edema) after atropine fails

IV Infusion Protocol:

1 mg in 500 mL NS
Start at 2–10 mcg/min
Titrate upward every 3–5 minutes to effect
Monitor: HR, BP, ECG continuously

D. SEPTIC/CARDIOGENIC SHOCK

"The α causes vasoconstriction, while β has positive inotropic and chronotropic effects. At higher doses, epinephrine has a similar profile (at lower doses, the β effects predominate) but is associated with more adverse effects." — Harrison's Principles of Internal Medicine, 22e

Used when noradrenaline is insufficient (second-line vasopressor in septic shock)
Also used post-cardiac arrest for myocardial dysfunction
Dose: Infusion titrated from 0.01–1 mcg/kg/min
Higher doses → predominantly α effects (vasoconstriction)
Lower doses → predominantly β effects (inotropy)

5. Adverse Effects

Effect	Mechanism	Clinical Significance
Tachycardia	β₁	Most common adverse effect
Hypertension	α₁	Can precipitate stroke, pulmonary edema
Ventricular ectopy / VT	β₁ over-stimulation	Especially with high/prolonged doses
Myocardial ischemia	Increased O₂ demand, α coronary vasoconstriction	Risk in CAD patients
Pulmonary shunting	β₂ vasodilation	Worsens V/Q mismatch
Cerebral vasoconstriction	α₁ (high dose)	May worsen neurologic outcome post-arrest
Anxiety, tremor, headache	CNS/PNS stimulation	Common at lower doses
Hyperglycaemia	β₂ glycogenolysis	Monitor in diabetics
Tissue necrosis	α₁ extravasation	Use central/IO route; treat extravasation with phentolamine

6. Contraindications and Cautions

Situation	Consideration
Anaphylaxis	NO absolute contraindications — epinephrine is always given
Cardiac arrest	No absolute contraindications
Hypertension	Caution in non-emergency use
Coronary artery disease	Increased ischemia risk; caution with infusions
Hyperthyroidism	Enhanced sensitivity
β-blockers	Reduced β-response → give glucagon; α effects may be exaggerated
Alkaline IV solutions	Do not mix — inactivated
Pheochromocytoma	Relative CI — can precipitate hypertensive crisis

7. Concentration Guide — Critical for Safety

Concentration	Ratio	Use
1 mg/mL	1:1000	Anaphylaxis (IM), nebulisation
0.1 mg/mL	1:10,000	Cardiac arrest (IV), haemodynamic infusions
0.01 mg/mL	1:100,000	Local anaesthesia additive

⚠️ Medication error risk: Always confirm the concentration before administration. Administering 1:1000 IV instead of 1:10,000 delivers 10× the intended dose and can cause hypertensive crisis, arrhythmia, or death.

8. Summary — Decision Framework

EMERGENCY PRESENTATION
        │
        ├── ANAPHYLAXIS?
        │   ├── Epinephrine 0.3–0.5 mg IM (1:1000) anterolateral thigh
        │   ├── Repeat q5–15 min if needed
        │   ├── IV fluids, O₂, airway management
        │   └── Antihistamines + corticosteroids (adjunct only)
        │
        ├── CARDIAC ARREST (VF/pVT/PEA/Asystole)?
        │   ├── CPR + defibrillation (shockable rhythm)
        │   ├── Epinephrine 1 mg IV/IO (1:10,000)
        │   ├── Repeat every 3–5 min
        │   └── Amiodarone for refractory shockable rhythm
        │
        ├── BRADYCARDIA (haemodynamically unstable, atropine failed)?
        │   └── Epinephrine infusion 2–10 mcg/min IV, titrate
        │
        └── SEPTIC/CARDIOGENIC SHOCK (refractory)?
            └── Epinephrine infusion 0.01–1 mcg/kg/min, titrate

Sources: Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e | Miller's Anesthesia, 10e | Harrison's Principles of Internal Medicine, 22e | Roberts and Hedges' Clinical Procedures in Emergency Medicine | Fuster and Hurst's The Heart, 15e

Create a quick reference PDF on epinephrine dosing and protocols for emergency use

Reading File

Running Command

ls -la /home/daytona/workspace/

Running Command

mkdir -p /home/daytona/workspace/epinephrine-qr && python3 -c "import reportlab; print('reportlab ok')" && python3 -c "from reportlab.lib.pagesizes import A4; print('A4 ok')"

Writing File

~/epinephrine-qr/build_pdf.py


from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import mm
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether
)
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_RIGHT
from reportlab.platypus import PageBreak

# ── Colour palette ──────────────────────────────────────────────────────────
RED         = colors.HexColor("#C0392B")
DARK_RED    = colors.HexColor("#922B21")
AMBER       = colors.HexColor("#E67E22")
GREEN       = colors.HexColor("#1E8449")
DARK_GREEN  = colors.HexColor("#145A32")
BLUE        = colors.HexColor("#1A5276")
LIGHT_BLUE  = colors.HexColor("#D6EAF8")
LIGHT_RED   = colors.HexColor("#FADBD8")
LIGHT_AMBER = colors.HexColor("#FDEBD0")
LIGHT_GREEN = colors.HexColor("#D5F5E3")
LIGHT_GREY  = colors.HexColor("#F2F3F4")
MID_GREY    = colors.HexColor("#BDC3C7")
DARK_GREY   = colors.HexColor("#2C3E50")
WHITE       = colors.white
BLACK       = colors.black

W, H = A4  # 595.27 x 841.89 pt

# ── Styles ───────────────────────────────────────────────────────────────────
styles = getSampleStyleSheet()

def S(name, **kw):
    return ParagraphStyle(name, **kw)

TITLE = S("TITLE",
    fontSize=22, fontName="Helvetica-Bold", textColor=WHITE,
    alignment=TA_CENTER, spaceAfter=2)

SUBTITLE = S("SUBTITLE",
    fontSize=11, fontName="Helvetica", textColor=WHITE,
    alignment=TA_CENTER, spaceAfter=0)

H1 = S("H1",
    fontSize=11, fontName="Helvetica-Bold", textColor=WHITE,
    alignment=TA_LEFT, spaceBefore=4, spaceAfter=2)

H2 = S("H2",
    fontSize=9.5, fontName="Helvetica-Bold", textColor=DARK_GREY,
    spaceBefore=3, spaceAfter=1)

BODY = S("BODY",
    fontSize=8.5, fontName="Helvetica", textColor=DARK_GREY,
    spaceBefore=1, spaceAfter=1, leading=11)

BODY_B = S("BODY_B",
    fontSize=8.5, fontName="Helvetica-Bold", textColor=DARK_GREY,
    spaceBefore=1, spaceAfter=1, leading=11)

WARN = S("WARN",
    fontSize=8, fontName="Helvetica-Bold", textColor=RED,
    alignment=TA_CENTER, spaceBefore=2, spaceAfter=2)

FOOTER = S("FOOTER",
    fontSize=7, fontName="Helvetica", textColor=MID_GREY,
    alignment=TA_CENTER)

TBL_HDR = S("TBL_HDR",
    fontSize=8, fontName="Helvetica-Bold", textColor=WHITE,
    alignment=TA_CENTER, leading=10)

TBL_CELL = S("TBL_CELL",
    fontSize=8, fontName="Helvetica", textColor=DARK_GREY,
    alignment=TA_LEFT, leading=10)

TBL_CELL_B = S("TBL_CELL_B",
    fontSize=8, fontName="Helvetica-Bold", textColor=DARK_GREY,
    alignment=TA_LEFT, leading=10)

TBL_CELL_C = S("TBL_CELL_C",
    fontSize=8, fontName="Helvetica", textColor=DARK_GREY,
    alignment=TA_CENTER, leading=10)

ALERT = S("ALERT",
    fontSize=8.5, fontName="Helvetica-Bold", textColor=DARK_RED,
    alignment=TA_CENTER, spaceBefore=3, spaceAfter=3)

# ── Helper: section header bar ───────────────────────────────────────────────
def section_bar(title, bg=BLUE, text_color=WHITE):
    data = [[Paragraph(title, S("tmp", fontSize=10, fontName="Helvetica-Bold",
                                 textColor=text_color, alignment=TA_LEFT))]]
    t = Table(data, colWidths=[W - 28*mm])
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), bg),
        ("LEFTPADDING",  (0,0), (-1,-1), 6),
        ("RIGHTPADDING", (0,0), (-1,-1), 6),
        ("TOPPADDING",   (0,0), (-1,-1), 4),
        ("BOTTOMPADDING",(0,0), (-1,-1), 4),
        ("ROUNDEDCORNERS", [3]),
    ]))
    return t

# ── Helper: two-column layout ────────────────────────────────────────────────
def two_col(left_content, right_content, left_w=None, right_w=None):
    total = W - 28*mm
    if left_w is None:
        left_w = total * 0.49
    if right_w is None:
        right_w = total * 0.49
    gap = total - left_w - right_w
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        ("TOPPADDING", (0,0), (-1,-1), 0),
        ("BOTTOMPADDING", (0,0), (-1,-1), 0),
    ]))
    return t

# ── Document ─────────────────────────────────────────────────────────────────
out_path = "/home/daytona/workspace/epinephrine-qr/Epinephrine_Quick_Reference.pdf"

doc = SimpleDocTemplate(
    out_path,
    pagesize=A4,
    leftMargin=14*mm, rightMargin=14*mm,
    topMargin=14*mm, bottomMargin=14*mm,
)

story = []

# ═══════════════════════════════════════════════════════════════════════════
# HEADER BANNER
# ═══════════════════════════════════════════════════════════════════════════
header_data = [
    [Paragraph("⚕ EPINEPHRINE (ADRENALINE)", TITLE)],
    [Paragraph("Emergency Dosing &amp; Protocol Quick Reference", SUBTITLE)],
    [Paragraph("For trained healthcare professionals only  |  Always confirm dose/concentration before administration", SUBTITLE)],
]
header_tbl = Table(header_data, colWidths=[W - 28*mm])
header_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), RED),
    ("TOPPADDING",    (0,0), (-1,-1), 6),
    ("BOTTOMPADDING", (0,0), (-1,-1), 6),
    ("LEFTPADDING",   (0,0), (-1,-1), 8),
    ("RIGHTPADDING",  (0,0), (-1,-1), 8),
    ("LINEBELOW",     (0,-1), (-1,-1), 2, DARK_RED),
]))
story.append(header_tbl)
story.append(Spacer(1, 4*mm))

# ═══════════════════════════════════════════════════════════════════════════
# CONCENTRATION GUIDE — CRITICAL SAFETY BOX
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_bar("⚠  CONCENTRATION GUIDE — KNOW BEFORE YOU DRAW", bg=DARK_RED))
story.append(Spacer(1, 1.5*mm))

conc_data = [
    [Paragraph("Ratio", TBL_HDR), Paragraph("Concentration", TBL_HDR),
     Paragraph("Volume for 1 mg", TBL_HDR), Paragraph("Clinical Use", TBL_HDR)],
    [Paragraph("1:1,000", TBL_CELL_B), Paragraph("1 mg/mL", TBL_CELL_C),
     Paragraph("1 mL", TBL_CELL_C),
     Paragraph("Anaphylaxis IM · Subcutaneous · Nebulisation", TBL_CELL)],
    [Paragraph("1:10,000", TBL_CELL_B), Paragraph("0.1 mg/mL", TBL_CELL_C),
     Paragraph("10 mL", TBL_CELL_C),
     Paragraph("Cardiac arrest IV/IO · Haemodynamic infusions", TBL_CELL)],
    [Paragraph("1:100,000", TBL_CELL_B), Paragraph("0.01 mg/mL", TBL_CELL_C),
     Paragraph("100 mL", TBL_CELL_C),
     Paragraph("Local anaesthesia additive (not emergency)", TBL_CELL)],
]
conc_tbl = Table(conc_data, colWidths=[28*mm, 32*mm, 32*mm, None])
conc_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), DARK_RED),
    ("BACKGROUND",    (0,1), (-1,1), LIGHT_RED),
    ("BACKGROUND",    (0,2), (-1,2), LIGHT_AMBER),
    ("BACKGROUND",    (0,3), (-1,3), LIGHT_GREY),
    ("BOX",           (0,0), (-1,-1), 0.5, MID_GREY),
    ("INNERGRID",     (0,0), (-1,-1), 0.3, MID_GREY),
    ("TOPPADDING",    (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("LEFTPADDING",   (0,0), (-1,-1), 4),
    ("RIGHTPADDING",  (0,0), (-1,-1), 4),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
]))
story.append(conc_tbl)

warn_data = [[Paragraph(
    "⛔  NEVER give 1:1,000 IV — this is 10× the IV cardiac arrest dose and can cause fatal hypertension/arrhythmia",
    WARN)]]
warn_tbl = Table(warn_data, colWidths=[W - 28*mm])
warn_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), LIGHT_RED),
    ("BOX",           (0,0), (-1,-1), 1, RED),
    ("TOPPADDING",    (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
]))
story.append(Spacer(1, 1*mm))
story.append(warn_tbl)
story.append(Spacer(1, 3*mm))

# ═══════════════════════════════════════════════════════════════════════════
# SECTION 1 — ANAPHYLAXIS  |  SECTION 2 — CARDIAC ARREST  (side by side)
# ═══════════════════════════════════════════════════════════════════════════

col_w = (W - 28*mm - 3*mm) / 2  # two equal columns with 3 mm gap

# ── LEFT: ANAPHYLAXIS ────────────────────────────────────────────────────
ana_story = []

# Header
ah = Table([[Paragraph("🔴  ANAPHYLAXIS", S("tmp", fontSize=10,
    fontName="Helvetica-Bold", textColor=WHITE, alignment=TA_LEFT))]],
    colWidths=[col_w])
ah.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), RED),
    ("LEFTPADDING", (0,0), (-1,-1), 5),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
]))
ana_story.append(ah)
ana_story.append(Spacer(1, 1.5*mm))

# Diagnosis criteria
ana_story.append(Paragraph("DIAGNOSTIC CRITERIA (any 1 of 3):", H2))
criteria = [
    ["1", "Urticaria/flushing/angioedema + ONE of:\n→ Respiratory distress/hypoxia\n→ Hypotension/collapse\n→ Organ dysfunction (syncope)"],
    ["2", "TWO or more after allergen exposure:\n→ Skin/mucosal involvement\n→ Respiratory compromise\n→ Hypotension\n→ Persistent GI symptoms"],
    ["3", "Hypotension after known allergen\n(even without skin signs)"],
]
crit_data = [
    [Paragraph("Criterion", TBL_HDR), Paragraph("Findings", TBL_HDR)]
] + [
    [Paragraph(r[0], TBL_CELL_B), Paragraph(r[1].replace("\n","<br/>"), TBL_CELL)]
    for r in criteria
]
crit_tbl = Table(crit_data, colWidths=[14*mm, col_w - 14*mm - 2*mm])
crit_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), RED),
    ("BACKGROUND",    (0,1), (-1,1), LIGHT_RED),
    ("BACKGROUND",    (0,2), (-1,2), LIGHT_GREY),
    ("BACKGROUND",    (0,3), (-1,3), LIGHT_RED),
    ("BOX",           (0,0), (-1,-1), 0.5, MID_GREY),
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    ("TOPPADDING",    (0,0), (-1,-1), 2),
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    ("LEFTPADDING",   (0,0), (-1,-1), 3),
    ("RIGHTPADDING",  (0,0), (-1,-1), 3),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
]))
ana_story.append(crit_tbl)
ana_story.append(Spacer(1, 2*mm))

# Epinephrine dosing
ana_story.append(Paragraph("EPINEPHRINE — FIRST-LINE (give immediately):", H2))
epi_ana = [
    [Paragraph("Patient", TBL_HDR), Paragraph("Route", TBL_HDR),
     Paragraph("Dose", TBL_HDR), Paragraph("Conc.", TBL_HDR)],
    [Paragraph("Adult", TBL_CELL_B), Paragraph("IM thigh", TBL_CELL_C),
     Paragraph("0.3–0.5 mg", TBL_CELL_B), Paragraph("1:1,000", TBL_CELL_C)],
    [Paragraph("Child", TBL_CELL_B), Paragraph("IM thigh", TBL_CELL_C),
     Paragraph("0.01 mg/kg\n(max 0.5 mg)", TBL_CELL_B), Paragraph("1:1,000", TBL_CELL_C)],
    [Paragraph("Collapse/\nArrest", TBL_CELL_B), Paragraph("IV slow", TBL_CELL_C),
     Paragraph("0.1–0.5 mg\nbolus", TBL_CELL_B), Paragraph("1:10,000", TBL_CELL_C)],
    [Paragraph("Infusion", TBL_CELL_B), Paragraph("IV", TBL_CELL_C),
     Paragraph("2–10 mcg/min\ntitrate", TBL_CELL_B), Paragraph("1 mg/500 mL\nNS", TBL_CELL_C)],
]
epi_ana_tbl = Table(epi_ana, colWidths=[18*mm, 18*mm, 24*mm, None])
epi_ana_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), RED),
    ("BACKGROUND",    (0,1), (-1,1), LIGHT_GREEN),
    ("BACKGROUND",    (0,2), (-1,2), LIGHT_GREY),
    ("BACKGROUND",    (0,3), (-1,3), LIGHT_GREEN),
    ("BACKGROUND",    (0,4), (-1,4), LIGHT_GREY),
    ("BOX",           (0,0), (-1,-1), 0.5, MID_GREY),
    ("INNERGRID",     (0,0), (-1,-1), 0.3, MID_GREY),
    ("TOPPADDING",    (0,0), (-1,-1), 2),
    ("BOTTOMPADDING", (0,0), (-1,-1), 2),
    ("LEFTPADDING",   (0,0), (-1,-1), 3),
    ("RIGHTPADDING",  (0,0), (-1,-1), 3),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
]))
ana_story.append(epi_ana_tbl)
ana_story.append(Spacer(1, 1*mm))
ana_story.append(Paragraph("→ Repeat IM every 5–15 min if no response · Site: anterolateral thigh", BODY))
ana_story.append(Spacer(1, 2*mm))

# Stepwise protocol
ana_story.append(Paragraph("TREATMENT STEPS:", H2))
steps = [
    ("1", "AIRWAY", "Intubate early if angioedema/stridor — DO NOT DELAY"),
    ("2", "EPINEPHRINE", "IM 0.3–0.5 mg (1:1,000) anterolateral thigh — IMMEDIATELY"),
    ("3", "O₂", "High-flow O₂ · Target SpO₂ > 90%"),
    ("4", "IV ACCESS", "Large-bore IV · Cardiac monitor · Pulse oximetry"),
    ("5", "IV FLUIDS", "NS 1–2 L bolus for hypotension (increased vascular permeability)"),
    ("6", "ADJUNCTS", "H₁ blocker + H₂ blocker + Corticosteroid (see below)"),
    ("7", "OBSERVE", "≥ 4–6 h · 8–12 h if severe (biphasic risk 3–11 h later)"),
]
step_data = [[Paragraph(s[0], TBL_CELL_B),
              Paragraph(s[1], TBL_CELL_B),
              Paragraph(s[2], TBL_CELL)] for s in steps]
step_tbl = Table(step_data, colWidths=[8*mm, 26*mm, None])
bg_cycle = [LIGHT_RED, LIGHT_GREY]
style_cmds = [
    ("BOX",           (0,0), (-1,-1), 0.5, MID_GREY),
    ("INNERGRID",     (0,0), (-1,-1), 0.3, MID_GREY),
    ("TOPPADDING",    (0,0), (-1,-1), 2),
    ("BOTTOMPADDING", (0,0), (-1,-1), 2),
    ("LEFTPADDING",   (0,0), (-1,-1), 3),
    ("RIGHTPADDING",  (0,0), (-1,-1), 3),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
]
for i in range(len(steps)):
    style_cmds.append(("BACKGROUND", (0,i), (-1,i), bg_cycle[i%2]))
step_tbl.setStyle(TableStyle(style_cmds))
ana_story.append(step_tbl)
ana_story.append(Spacer(1, 2*mm))

# Adjunct drugs
ana_story.append(Paragraph("ADJUNCT DRUGS (do NOT replace epinephrine):", H2))
adj = [
    [Paragraph("Drug", TBL_HDR), Paragraph("Dose", TBL_HDR), Paragraph("Note", TBL_HDR)],
    [Paragraph("Diphenhydramine", TBL_CELL), Paragraph("25–50 mg IV/IM", TBL_CELL_B), Paragraph("H₁ blocker · Urticaria/pruritus only", TBL_CELL)],
    [Paragraph("Ranitidine", TBL_CELL), Paragraph("50 mg IV", TBL_CELL_B), Paragraph("H₂ blocker · Complements H₁", TBL_CELL)],
    [Paragraph("Methylprednisolone", TBL_CELL), Paragraph("125 mg IV", TBL_CELL_B), Paragraph("Prevents biphasic · Onset 4–6 h", TBL_CELL)],
    [Paragraph("Salbutamol", TBL_CELL), Paragraph("2.5–5 mg neb", TBL_CELL_B), Paragraph("Persistent bronchospasm", TBL_CELL)],
    [Paragraph("Glucagon", TBL_CELL), Paragraph("1–2 mg IV", TBL_CELL_B), Paragraph("β-BLOCKER patients — bypasses adrenergic receptors", TBL_CELL)],
]
adj_tbl = Table(adj, colWidths=[30*mm, 26*mm, None])
adj_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), RED),
    ("BOX",           (0,0), (-1,-1), 0.5, MID_GREY),
    ("INNERGRID",     (0,0), (-1,-1), 0.3, MID_GREY),
    ("TOPPADDING",    (0,0), (-1,-1), 2),
    ("BOTTOMPADDING", (0,0), (-1,-1), 2),
    ("LEFTPADDING",   (0,0), (-1,-1), 3),
    ("RIGHTPADDING",  (0,0), (-1,-1), 3),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_GREY, WHITE]),
]))
ana_story.append(adj_tbl)

# Build left column as nested table
left_inner = Table([[x] for x in ana_story], colWidths=[col_w])
left_inner.setStyle(TableStyle([
    ("TOPPADDING", (0,0), (-1,-1), 0),
    ("BOTTOMPADDING", (0,0), (-1,-1), 1),
    ("LEFTPADDING", (0,0), (-1,-1), 0),
    ("RIGHTPADDING", (0,0), (-1,-1), 0),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))

# ── RIGHT: CARDIAC ARREST ────────────────────────────────────────────────
ca_story = []

# Header
cah = Table([[Paragraph("🔵  CARDIAC ARREST (ACLS/PALS)", S("tmp", fontSize=10,
    fontName="Helvetica-Bold", textColor=WHITE, alignment=TA_LEFT))]],
    colWidths=[col_w])
cah.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), BLUE),
    ("LEFTPADDING", (0,0), (-1,-1), 5),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
]))
ca_story.append(cah)
ca_story.append(Spacer(1, 1.5*mm))

# Indications
ca_story.append(Paragraph("INDICATIONS:", H2))
inds = [
    "Ventricular fibrillation (VF) unresponsive to shock",
    "Pulseless VT (pVT) unresponsive to shock",
    "Asystole",
    "Pulseless Electrical Activity (PEA)",
    "Haemodynamically unstable bradycardia (atropine failed)",
]
ind_data = [[Paragraph(f"• {i}", TBL_CELL)] for i in inds]
ind_tbl = Table(ind_data, colWidths=[col_w - 2*mm])
ind_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), LIGHT_BLUE),
    ("BOX",           (0,0), (-1,-1), 0.5, BLUE),
    ("INNERGRID",     (0,0), (-1,-1), 0.3, MID_GREY),
    ("TOPPADDING",    (0,0), (-1,-1), 2),
    ("BOTTOMPADDING", (0,0), (-1,-1), 2),
    ("LEFTPADDING",   (0,0), (-1,-1), 5),
    ("RIGHTPADDING",  (0,0), (-1,-1), 3),
]))
ca_story.append(ind_tbl)
ca_story.append(Spacer(1, 2*mm))

# Adult dose
ca_story.append(Paragraph("ADULT CARDIAC ARREST PROTOCOL:", H2))
adult_ca = [
    [Paragraph("Phase", TBL_HDR), Paragraph("Action", TBL_HDR)],
    [Paragraph("0 min", TBL_CELL_B), Paragraph("CPR — 30:2 · Rate ≥ 100/min · Depth ≥ 5 cm", TBL_CELL)],
    [Paragraph("ASAP", TBL_CELL_B), Paragraph("Defibrillate if VF/pVT (do not delay for drugs)", TBL_CELL)],
    [Paragraph("After 2nd shock\nor PEA/Asystole", TBL_CELL_B), Paragraph("Epinephrine 1 mg IV/IO (1:10,000 = 10 mL)\nFlush ≥ 20 mL NS · Continue CPR 30–60 s", TBL_CELL)],
    [Paragraph("Every 3–5 min", TBL_CELL_B), Paragraph("Repeat epinephrine 1 mg IV/IO\n(no maximum dose limit)", TBL_CELL)],
    [Paragraph("Refractory\nVF/pVT", TBL_CELL_B), Paragraph("Amiodarone 300 mg IV bolus after 3rd shock", TBL_CELL)],
    [Paragraph("ROSC", TBL_CELL_B), Paragraph("Post-resuscitation care · Monitor glucose · Temperature", TBL_CELL)],
]
adult_ca_tbl = Table(adult_ca, colWidths=[28*mm, None])
adult_ca_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), BLUE),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_GREY, LIGHT_BLUE]),
    ("BOX",           (0,0), (-1,-1), 0.5, MID_GREY),
    ("INNERGRID",     (0,0), (-1,-1), 0.3, MID_GREY),
    ("TOPPADDING",    (0,0), (-1,-1), 2),
    ("BOTTOMPADDING", (0,0), (-1,-1), 2),
    ("LEFTPADDING",   (0,0), (-1,-1), 3),
    ("RIGHTPADDING",  (0,0), (-1,-1), 3),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
]))
ca_story.append(adult_ca_tbl)
ca_story.append(Spacer(1, 2*mm))

# Paediatric dose
ca_story.append(Paragraph("PAEDIATRIC CARDIAC ARREST DOSE:", H2))
ped_data = [
    [Paragraph("Route", TBL_HDR), Paragraph("Dose", TBL_HDR), Paragraph("Conc.", TBL_HDR), Paragraph("Interval", TBL_HDR)],
    [Paragraph("IV / IO", TBL_CELL_B), Paragraph("0.01 mg/kg\n(max 1 mg)", TBL_CELL_B), Paragraph("1:10,000", TBL_CELL_C), Paragraph("Every\n3–5 min", TBL_CELL_C)],
]
ped_tbl = Table(ped_data, colWidths=[20*mm, 26*mm, 22*mm, None])
ped_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), BLUE),
    ("BACKGROUND",    (0,1), (-1,1), LIGHT_BLUE),
    ("BOX",           (0,0), (-1,-1), 0.5, MID_GREY),
    ("INNERGRID",     (0,0), (-1,-1), 0.3, MID_GREY),
    ("TOPPADDING",    (0,0), (-1,-1), 2),
    ("BOTTOMPADDING", (0,0), (-1,-1), 2),
    ("LEFTPADDING",   (0,0), (-1,-1), 3),
    ("RIGHTPADDING",  (0,0), (-1,-1), 3),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
]))
ca_story.append(ped_tbl)
ca_story.append(Paragraph("→ Give early in non-shockable arrest · Not effective if &gt;15 min after EMS arrival", BODY))
ca_story.append(Paragraph("→ ET route no longer recommended (poor absorption)", BODY))
ca_story.append(Spacer(1, 2*mm))

# Bradycardia infusion
ca_story.append(Paragraph("BRADYCARDIA INFUSION (haemodynamically unstable, atropine failed):", H2))
brady_data = [
    [Paragraph("Preparation", TBL_HDR), Paragraph("Start Rate", TBL_HDR), Paragraph("Titration", TBL_HDR)],
    [Paragraph("1 mg in 500 mL NS", TBL_CELL_B), Paragraph("2–10 mcg/min", TBL_CELL_B), Paragraph("↑ every 3–5 min\nto effect", TBL_CELL)],
]
brady_tbl = Table(brady_data, colWidths=[36*mm, 28*mm, None])
brady_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), BLUE),
    ("BACKGROUND",    (0,1), (-1,1), LIGHT_BLUE),
    ("BOX",           (0,0), (-1,-1), 0.5, MID_GREY),
    ("INNERGRID",     (0,0), (-1,-1), 0.3, MID_GREY),
    ("TOPPADDING",    (0,0), (-1,-1), 2),
    ("BOTTOMPADDING", (0,0), (-1,-1), 2),
    ("LEFTPADDING",   (0,0), (-1,-1), 3),
    ("RIGHTPADDING",  (0,0), (-1,-1), 3),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
]))
ca_story.append(brady_tbl)
ca_story.append(Spacer(1, 2*mm))

# Shock infusion
ca_story.append(Paragraph("SEPTIC/CARDIOGENIC SHOCK INFUSION:", H2))
shock_data = [
    [Paragraph("Dose Range", TBL_HDR), Paragraph("Predominant Effect", TBL_HDR)],
    [Paragraph("0.01–0.1 mcg/kg/min", TBL_CELL_B), Paragraph("β predominant → inotropy, chronotropy", TBL_CELL)],
    [Paragraph("0.1–1 mcg/kg/min", TBL_CELL_B), Paragraph("α predominant → vasoconstriction, ↑ SVR", TBL_CELL)],
]
shock_tbl = Table(shock_data, colWidths=[40*mm, None])
shock_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), BLUE),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_BLUE, LIGHT_GREY]),
    ("BOX",           (0,0), (-1,-1), 0.5, MID_GREY),
    ("INNERGRID",     (0,0), (-1,-1), 0.3, MID_GREY),
    ("TOPPADDING",    (0,0), (-1,-1), 2),
    ("BOTTOMPADDING", (0,0), (-1,-1), 2),
    ("LEFTPADDING",   (0,0), (-1,-1), 3),
    ("RIGHTPADDING",  (0,0), (-1,-1), 3),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
]))
ca_story.append(shock_tbl)

# Build right column as nested table
right_inner = Table([[x] for x in ca_story], colWidths=[col_w])
right_inner.setStyle(TableStyle([
    ("TOPPADDING", (0,0), (-1,-1), 0),
    ("BOTTOMPADDING", (0,0), (-1,-1), 1),
    ("LEFTPADDING", (0,0), (-1,-1), 0),
    ("RIGHTPADDING", (0,0), (-1,-1), 0),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))

# Two-column main table
main_cols = Table([[left_inner, Spacer(3*mm, 1), right_inner]],
                  colWidths=[col_w, 3*mm, col_w])
main_cols.setStyle(TableStyle([
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ("TOPPADDING",    (0,0), (-1,-1), 0),
    ("BOTTOMPADDING", (0,0), (-1,-1), 0),
    ("LEFTPADDING",   (0,0), (-1,-1), 0),
    ("RIGHTPADDING",  (0,0), (-1,-1), 0),
]))
story.append(main_cols)
story.append(Spacer(1, 3*mm))

# ═══════════════════════════════════════════════════════════════════════════
# MECHANISM SUMMARY BAR
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_bar("MECHANISM OF ACTION — RECEPTOR SUMMARY", bg=DARK_GREY))
story.append(Spacer(1, 1.5*mm))

moa_data = [
    [Paragraph("Receptor", TBL_HDR), Paragraph("Location", TBL_HDR),
     Paragraph("Effect", TBL_HDR), Paragraph("Clinical Benefit", TBL_HDR)],
    [Paragraph("α₁", TBL_CELL_B), Paragraph("Vascular SM", TBL_CELL),
     Paragraph("Vasoconstriction ↑ SVR", TBL_CELL),
     Paragraph("↑ BP · ↓ Angioedema · ↑ Coronary/cerebral perfusion pressure", TBL_CELL)],
    [Paragraph("β₁", TBL_CELL_B), Paragraph("Heart", TBL_CELL),
     Paragraph("↑ HR · ↑ Contractility · ↑ AV conduction", TBL_CELL),
     Paragraph("↑ Cardiac output · Restores rhythm · Treats bradycardia", TBL_CELL)],
    [Paragraph("β₂", TBL_CELL_B), Paragraph("Bronchi · Mast cells", TBL_CELL),
     Paragraph("Bronchodilation · Inhibits degranulation · Vasodilation", TBL_CELL),
     Paragraph("Reverses bronchospasm · Stops mediator release in anaphylaxis", TBL_CELL)],
    [Paragraph("Signal\nPath", TBL_CELL_B), Paragraph("β-receptor → Gs protein", TBL_CELL),
     Paragraph("→ Adenylyl cyclase → cAMP → PKA → Ca²⁺ handling", TBL_CELL),
     Paragraph("↑ Rate of contraction · ↑ Peak force · ↑ Rate of relaxation (lusitropy)", TBL_CELL)],
]
moa_tbl = Table(moa_data, colWidths=[16*mm, 32*mm, 56*mm, None])
moa_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), DARK_GREY),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_GREY, WHITE, LIGHT_GREY, WHITE]),
    ("BOX",           (0,0), (-1,-1), 0.5, MID_GREY),
    ("INNERGRID",     (0,0), (-1,-1), 0.3, MID_GREY),
    ("TOPPADDING",    (0,0), (-1,-1), 2),
    ("BOTTOMPADDING", (0,0), (-1,-1), 2),
    ("LEFTPADDING",   (0,0), (-1,-1), 4),
    ("RIGHTPADDING",  (0,0), (-1,-1), 4),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
]))
story.append(moa_tbl)
story.append(Spacer(1, 3*mm))

# ═══════════════════════════════════════════════════════════════════════════
# ADVERSE EFFECTS + CAUTIONS (bottom row, 3 columns)
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_bar("ADVERSE EFFECTS · CAUTIONS · DISCHARGE PLANNING", bg=AMBER))
story.append(Spacer(1, 1.5*mm))

col3 = (W - 28*mm - 4*mm) / 3

# Adverse effects
ae_header = Table([[Paragraph("⚠ ADVERSE EFFECTS", S("tmp", fontSize=9, fontName="Helvetica-Bold", textColor=WHITE, alignment=TA_LEFT))]],
                  colWidths=[col3])
ae_header.setStyle(TableStyle([("BACKGROUND",(0,0),(-1,-1), AMBER),
    ("LEFTPADDING",(0,0),(-1,-1),4),("TOPPADDING",(0,0),(-1,-1),3),("BOTTOMPADDING",(0,0),(-1,-1),3)]))
ae_items = [
    "Tachycardia (most common)",
    "Hypertension → stroke / pulm. oedema",
    "Ventricular ectopy / VT (high dose)",
    "Myocardial ischaemia (↑ O₂ demand)",
    "Pulmonary shunting",
    "Cerebral vasoconstriction (post-arrest)",
    "Hyperglycaemia",
    "Tissue necrosis (extravasation)",
]
ae_data = [[Paragraph(f"• {i}", TBL_CELL)] for i in ae_items]
ae_tbl = Table(ae_data, colWidths=[col3 - 2*mm])
ae_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), LIGHT_AMBER),
    ("BOX",           (0,0), (-1,-1), 0.5, AMBER),
    ("INNERGRID",     (0,0), (-1,-1), 0.3, MID_GREY),
    ("TOPPADDING",    (0,0), (-1,-1), 1.5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 1.5),
    ("LEFTPADDING",   (0,0), (-1,-1), 5),
]))

# Cautions
caut_header = Table([[Paragraph("🔶 CAUTIONS / SPECIAL CASES", S("tmp", fontSize=9, fontName="Helvetica-Bold", textColor=WHITE, alignment=TA_LEFT))]],
                    colWidths=[col3])
caut_header.setStyle(TableStyle([("BACKGROUND",(0,0),(-1,-1), AMBER),
    ("LEFTPADDING",(0,0),(-1,-1),4),("TOPPADDING",(0,0),(-1,-1),3),("BOTTOMPADDING",(0,0),(-1,-1),3)]))
cauts = [
    ("Anaphylaxis", "NO absolute contraindications — always give"),
    ("β-Blockers", "Add glucagon 1–2 mg IV; α effects may ↑"),
    ("Cardiac arrest", "No absolute contraindications"),
    ("Alkaline solutions", "DO NOT MIX — inactivated"),
    ("CAD / hypertension", "Caution with infusions; ↑ ischaemia risk"),
    ("Extravasation", "Phentolamine local infiltration"),
    ("Hyperthyroidism", "Enhanced sensitivity; reduce dose"),
    ("Phaeochromocytoma", "Relative CI — hypertensive crisis risk"),
]
caut_data = [[Paragraph(f"<b>{c[0]}:</b> {c[1]}", TBL_CELL)] for c in cauts]
caut_tbl = Table(caut_data, colWidths=[col3 - 2*mm])
caut_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), LIGHT_AMBER),
    ("BOX",           (0,0), (-1,-1), 0.5, AMBER),
    ("INNERGRID",     (0,0), (-1,-1), 0.3, MID_GREY),
    ("TOPPADDING",    (0,0), (-1,-1), 1.5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 1.5),
    ("LEFTPADDING",   (0,0), (-1,-1), 5),
]))

# Discharge planning
disc_header = Table([[Paragraph("✅ DISCHARGE (Anaphylaxis)", S("tmp", fontSize=9, fontName="Helvetica-Bold", textColor=WHITE, alignment=TA_LEFT))]],
                    colWidths=[col3])
disc_header.setStyle(TableStyle([("BACKGROUND",(0,0),(-1,-1), GREEN),
    ("LEFTPADDING",(0,0),(-1,-1),4),("TOPPADDING",(0,0),(-1,-1),3),("BOTTOMPADDING",(0,0),(-1,-1),3)]))
disc_items = [
    "Observe ≥ 4–6 h (8–12 h if severe)",
    "Prescribe ≥ 2 EpiPen autoinjectors",
    "Antihistamine (diphenhydramine 25–50 mg PO q6–8h × 3–5 d)",
    "Prednisolone 40–60 mg/day × 3–5 d",
    "Written anaphylaxis action plan",
    "MedicAlert bracelet advice",
    "Avoid known allergen — education",
    "Allergy/immunology referral if severe/recurrent",
    "Switch β-blocker if patient on one",
]
disc_data = [[Paragraph(f"• {i}", TBL_CELL)] for i in disc_items]
disc_tbl = Table(disc_data, colWidths=[col3 - 2*mm])
disc_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), LIGHT_GREEN),
    ("BOX",           (0,0), (-1,-1), 0.5, GREEN),
    ("INNERGRID",     (0,0), (-1,-1), 0.3, MID_GREY),
    ("TOPPADDING",    (0,0), (-1,-1), 1.5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 1.5),
    ("LEFTPADDING",   (0,0), (-1,-1), 5),
]))

# 3-column layout
def build_col(header, tbl):
    inner = Table([[header],[tbl]], colWidths=[col3])
    inner.setStyle(TableStyle([
        ("TOPPADDING",    (0,0), (-1,-1), 0),
        ("BOTTOMPADDING", (0,0), (-1,-1), 0),
        ("LEFTPADDING",   (0,0), (-1,-1), 0),
        ("RIGHTPADDING",  (0,0), (-1,-1), 0),
        ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ]))
    return inner

bottom_row = Table([[build_col(ae_header, ae_tbl),
                     Spacer(2*mm, 1),
                     build_col(caut_header, caut_tbl),
                     Spacer(2*mm, 1),
                     build_col(disc_header, disc_tbl)]],
                   colWidths=[col3, 2*mm, col3, 2*mm, col3])
bottom_row.setStyle(TableStyle([
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ("TOPPADDING",    (0,0), (-1,-1), 0),
    ("BOTTOMPADDING", (0,0), (-1,-1), 0),
    ("LEFTPADDING",   (0,0), (-1,-1), 0),
    ("RIGHTPADDING",  (0,0), (-1,-1), 0),
]))
story.append(bottom_row)
story.append(Spacer(1, 3*mm))

# ═══════════════════════════════════════════════════════════════════════════
# FOOTER
# ═══════════════════════════════════════════════════════════════════════════
HRFlowable(width="100%", thickness=0.5, color=MID_GREY)
footer_data = [[
    Paragraph(
        "Sources: Tintinalli's Emergency Medicine 9e · Miller's Anesthesia 10e · Harrison's Principles 22e · Roberts &amp; Hedges' Clinical Procedures in Emergency Medicine · ACLS/PALS Guidelines",
        FOOTER),
    Paragraph(
        "For trained healthcare professionals only. Verify all doses and concentrations independently before administration. Not a substitute for clinical judgment.",
        S("FR", fontSize=6.5, fontName="Helvetica-Oblique", textColor=MID_GREY, alignment=TA_RIGHT))
]]
footer_tbl = Table(footer_data, colWidths=[(W-28*mm)*0.55, (W-28*mm)*0.45])
footer_tbl.setStyle(TableStyle([
    ("TOPPADDING",    (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 0),
    ("LEFTPADDING",   (0,0), (-1,-1), 0),
    ("RIGHTPADDING",  (0,0), (-1,-1), 0),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ("LINEABOVE",     (0,0), (-1,0), 0.5, MID_GREY),
]))
story.append(footer_tbl)

# ── Build ────────────────────────────────────────────────────────────────────
doc.build(story)
print(f"PDF written to: {out_path}")

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