const pptxgen = require("pptxgenjs");
const { execSync } = require("child_process");

// Fetch images
const imageUrls = [
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_bdeafeef7610b98c1313148f2edcdeda5bd5f3adba2ade5ad110c32d716bfb1c.jpg",   // echo hypovolemic shock
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_37113599f423d6e81d9dbdc0cf8391dc0c17d4317f485b633047f1e7a66b6a72.jpg",   // gastroscopy UGI bleeding
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_79d6a6f93ec405d342788a7b84126e1fd1b7bd1fa0bf0c413286fefe5874a723.jpg",   // CT shock IVC flat
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_56f2259480d4aa374de3c081ad8ac68f41cc4bad01f1e68b546997cc3e722fd7.jpg",   // Dieulafoy endoscopy
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_608c1980be7581548a3262c001885c43ea0423a8079b941df88317d1d0468d0a.jpg",   // RBC scintigraphy GI bleed
];

console.log("Fetching images...");
let images;
try {
  const result = execSync(
    `node /home/daytona/skills/shared/scripts/fetch_images.js "${imageUrls[0]}" "${imageUrls[1]}" "${imageUrls[2]}" "${imageUrls[3]}"`,
    { timeout: 60000 }
  ).toString();
  images = JSON.parse(result);
  console.log("Images fetched:", images.map(i => i.error ? "ERROR: " + i.error : "OK").join(", "));
} catch (e) {
  console.error("Image fetch failed:", e.message);
  images = imageUrls.map(url => ({ url, base64: null, error: "fetch failed" }));
}

// Color Palette
const DARK_RED = "8B0000";
const CRIMSON = "C0392B";
const BLOOD_RED = "A93226";
const DEEP_NAVY = "1A1A2E";
const DARK_SLATE = "16213E";
const MID_BLUE = "0F3460";
const ACCENT_GOLD = "F5A623";
const LIGHT_GOLD = "F8D27D";
const WHITE = "FFFFFF";
const OFF_WHITE = "F5F5F5";
const LIGHT_GREY = "D5D8DC";
const BODY_TEXT = "E8E8E8";

const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.33" x 7.5"
pres.title = "Hypovolemic Shock in GI Bleeding";
pres.author = "Medical Education";

// ─────────────────────────────────────────────────────────────────
// HELPER FUNCTIONS
// ─────────────────────────────────────────────────────────────────
function addSlideBackground(slide, color) {
  slide.background = { color };
}

function addTitle(slide, titleText, subtitleText, titleColor, subtitleColor) {
  // Decorative top bar
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.33, h: 0.08, fill: { color: CRIMSON } });
  slide.addText(titleText, {
    x: 0.4, y: 0.15, w: 12.5, h: 0.7,
    fontSize: 28, bold: true, color: titleColor || WHITE,
    fontFace: "Calibri", charSpacing: 1,
  });
  if (subtitleText) {
    slide.addText(subtitleText, {
      x: 0.4, y: 0.85, w: 12.5, h: 0.35,
      fontSize: 13, color: subtitleColor || LIGHT_GOLD,
      fontFace: "Calibri", italic: true,
    });
  }
  // Bottom bar
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 7.42, w: 13.33, h: 0.08, fill: { color: CRIMSON } });
}

function addBullets(slide, items, x, y, w, h, fontSize, color, bold, indent) {
  const bullets = items.map((item, i) => ({
    text: item,
    options: {
      bullet: { indent: indent || 15 },
      breakLine: i < items.length - 1,
      fontSize: fontSize || 13,
      color: color || BODY_TEXT,
      bold: bold || false,
      fontFace: "Calibri",
    }
  }));
  slide.addText(bullets, { x, y, w, h, valign: "top" });
}

function addSectionLabel(slide, text, x, y, w, color) {
  slide.addShape(pres.ShapeType.rect, { x, y, w, h: 0.32, fill: { color: color || CRIMSON }, line: { color: color || CRIMSON } });
  slide.addText(text, {
    x: x + 0.08, y: y + 0.02, w: w - 0.16, h: 0.28,
    fontSize: 11, bold: true, color: WHITE, fontFace: "Calibri",
  });
}

function addInfoBox(slide, text, x, y, w, h, fillColor, textColor, fontSize) {
  slide.addShape(pres.ShapeType.rect, { x, y, w, h, fill: { color: fillColor || MID_BLUE }, line: { color: ACCENT_GOLD, pt: 1 } });
  slide.addText(text, {
    x: x + 0.1, y: y + 0.05, w: w - 0.2, h: h - 0.1,
    fontSize: fontSize || 12, color: textColor || WHITE, fontFace: "Calibri", valign: "top",
  });
}

// ─────────────────────────────────────────────────────────────────
// SLIDE 1: TITLE
// ─────────────────────────────────────────────────────────────────
{
  const slide = pres.addSlide();
  addSlideBackground(slide, DEEP_NAVY);

  // Full-bleed dramatic accent
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.33, h: 7.5, fill: { color: DEEP_NAVY } });
  // Left blood-red panel
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 4.2, h: 7.5, fill: { color: DARK_RED } });
  // Diagonal accent shape
  slide.addShape(pres.ShapeType.rect, { x: 3.8, y: 0, w: 0.7, h: 7.5, fill: { color: BLOOD_RED }, line: { color: BLOOD_RED } });

  // Left panel text: vertical label
  slide.addText("EMERGENCY MEDICINE", {
    x: 0.18, y: 2.2, w: 3.5, h: 0.5,
    fontSize: 11, color: LIGHT_GOLD, bold: true, charSpacing: 4, fontFace: "Calibri", align: "left",
  });

  slide.addText("CRITICAL CARE", {
    x: 0.18, y: 2.75, w: 3.5, h: 0.4,
    fontSize: 11, color: LIGHT_GREY, charSpacing: 3, fontFace: "Calibri", align: "left",
  });

  // Red cross / medical icon simulation
  slide.addShape(pres.ShapeType.rect, { x: 1.2, y: 3.4, w: 1.6, h: 0.35, fill: { color: WHITE }, line: { color: WHITE } });
  slide.addShape(pres.ShapeType.rect, { x: 1.77, y: 2.95, w: 0.45, h: 1.25, fill: { color: WHITE }, line: { color: WHITE } });

  // Main title
  slide.addText("HYPOVOLEMIC SHOCK", {
    x: 4.7, y: 1.5, w: 8.3, h: 1.1,
    fontSize: 44, bold: true, color: WHITE,
    fontFace: "Calibri", charSpacing: 2,
  });
  slide.addText("in Gastrointestinal Bleeding", {
    x: 4.7, y: 2.65, w: 8.3, h: 0.7,
    fontSize: 26, color: ACCENT_GOLD, fontFace: "Calibri", italic: true,
  });

  // Gold divider
  slide.addShape(pres.ShapeType.rect, { x: 4.7, y: 3.5, w: 7.0, h: 0.06, fill: { color: ACCENT_GOLD } });

  // Subtitle content
  slide.addText([
    { text: "Pathophysiology  •  Classification  •  Clinical Features", options: { breakLine: true } },
    { text: "Diagnosis  •  Step-by-Step Management", options: {} },
  ], {
    x: 4.7, y: 3.7, w: 8.3, h: 0.9,
    fontSize: 15, color: LIGHT_GREY, fontFace: "Calibri", align: "left",
  });

  // Topics overview pills
  const topics = ["Pathophysiology", "ATLS Classes", "Signs & Symptoms", "Lab & Imaging", "Treatment Protocol"];
  topics.forEach((t, i) => {
    const col = i % 3;
    const row = Math.floor(i / 3);
    slide.addShape(pres.ShapeType.roundRect, {
      x: 4.7 + col * 2.7, y: 5.0 + row * 0.65, w: 2.5, h: 0.45,
      fill: { color: MID_BLUE }, line: { color: ACCENT_GOLD, pt: 1 }, rectRadius: 0.1,
    });
    slide.addText(t, {
      x: 4.7 + col * 2.7 + 0.1, y: 5.0 + row * 0.65 + 0.06, w: 2.3, h: 0.33,
      fontSize: 11, color: ACCENT_GOLD, bold: true, fontFace: "Calibri", align: "center",
    });
  });

  // Date
  slide.addText("May 2026", {
    x: 4.7, y: 6.8, w: 8.3, h: 0.3,
    fontSize: 10, color: LIGHT_GREY, fontFace: "Calibri",
  });
}

// ─────────────────────────────────────────────────────────────────
// SLIDE 2: OVERVIEW & DEFINITION
// ─────────────────────────────────────────────────────────────────
{
  const slide = pres.addSlide();
  addSlideBackground(slide, DARK_SLATE);
  addTitle(slide, "Overview: Shock & GI Bleeding", "Definitions, Epidemiology, and the Clinical Challenge");

  // Left column: definition
  slide.addShape(pres.ShapeType.rect, { x: 0.3, y: 1.3, w: 6.0, h: 5.7, fill: { color: MID_BLUE }, line: { color: CRIMSON, pt: 2 } });
  addSectionLabel(slide, "WHAT IS HYPOVOLEMIC SHOCK?", 0.3, 1.3, 6.0, CRIMSON);
  const defItems = [
    "A state of circulatory failure resulting from inadequate intravascular volume",
    "Most commonly encountered shock in surgical & emergency practice",
    "Characterized by ↓ venous return → ↓ cardiac output → inadequate tissue perfusion",
    "Blood loss >20% of circulating volume required to produce the full syndrome",
    "GI bleeding is a leading non-traumatic cause of hemorrhagic hypovolemic shock",
    "Pathological hallmark: increased SVR + decreased CO ('cold shock')",
    "Untreated → cellular hypoxia → anaerobic metabolism → lactic acidosis → organ failure",
  ];
  addBullets(slide, defItems, 0.45, 1.75, 5.7, 4.9, 12, BODY_TEXT, false, 18);

  // Right column: epidemiology
  slide.addShape(pres.ShapeType.rect, { x: 6.8, y: 1.3, w: 6.2, h: 2.6, fill: { color: "1E2D45" }, line: { color: ACCENT_GOLD, pt: 1 } });
  addSectionLabel(slide, "EPIDEMIOLOGY", 6.8, 1.3, 6.2, MID_BLUE);
  const epidItems = [
    "Upper GI bleeding (UGIB): ~100/100,000 admissions/year",
    "UGIB mortality: 2–10% overall; up to 15% in cirrhosis",
    "Lower GI bleeding (LGIB): stops spontaneously in 80–85%",
    "LGIB mortality: 2–4%; higher with hemodynamic compromise",
    "~10–15% of hematochezia cases originate from massive UGIB",
  ];
  addBullets(slide, epidItems, 6.95, 1.75, 5.9, 2.1, 11.5, BODY_TEXT);

  // Right lower: GI Bleed classification
  slide.addShape(pres.ShapeType.rect, { x: 6.8, y: 4.1, w: 6.2, h: 2.9, fill: { color: "1E2D45" }, line: { color: ACCENT_GOLD, pt: 1 } });
  addSectionLabel(slide, "GI BLEEDING: UPPER vs LOWER", 6.8, 4.1, 6.2, MID_BLUE);
  const giItems = [
    "UGIB (proximal to Ligament of Treitz): peptic ulcer, varices, Mallory-Weiss tear, Dieulafoy lesion, angiodysplasia, aortoenteric fistula",
    "LGIB (distal to Ligament of Treitz): diverticulosis, angiodysplasia, IBD, ischemic colitis, neoplasia, post-polypectomy",
    "Hematemesis / coffee-ground emesis → UGIB",
    "Melena (black tarry stool, ≥50 mL blood) → usually proximal",
    "Hematochezia (bright red blood per rectum) → usually LGIB; massive UGIB if with hemodynamic instability",
  ];
  addBullets(slide, giItems, 6.95, 4.55, 5.9, 2.4, 11, BODY_TEXT);
}

// ─────────────────────────────────────────────────────────────────
// SLIDE 3: PATHOPHYSIOLOGY PART 1 — HEMORRHAGE & COMPENSATORY REFLEXES
// ─────────────────────────────────────────────────────────────────
{
  const slide = pres.addSlide();
  addSlideBackground(slide, DARK_SLATE);
  addTitle(slide, "Pathophysiology — Part 1: Hemorrhage & Compensatory Mechanisms",
    "Guyton & Hall Physiology | Mulholland & Greenfield's Surgery");

  // Step flow boxes for cascade
  const steps = [
    { label: "1. BLOOD LOSS", text: "Loss of intravascular volume\n↓ Circulating blood volume\n↓ Venous return (preload)\n↓ End-diastolic volume" },
    { label: "2. ↓ CARDIAC OUTPUT", text: "Starling's law: ↓ preload → ↓ stroke volume\n↓ Cardiac output (CO)\nArterial pressure begins to fall\n(10% loss: no change; >15%: CO drops first)" },
    { label: "3. SYMPATHETIC ACTIVATION", text: "Baroreceptors detect ↓ arterial pressure\nMassive SNS discharge\n↑ HR (up to 160–180 bpm)\nPeripheral vasoconstriction (↑ SVR)" },
    { label: "4. NEUROENDOCRINE RESPONSE", text: "↑ Renin → ↑ Angiotensin II → vasoconstriction + ↓ urine output\n↑ ADH/Vasopressin → ↑ free water retention\n↑ Aldosterone → ↑ Na+ & H2O reabsorption\nVenous constriction → ↑ venous return" },
    { label: "5. CELLULAR HYPOXIA", text: "Prolonged ↓ O2 delivery to tissues\nShift to anaerobic glycolysis\nLactic acid accumulates → metabolic acidosis\n'Vicious cycle' of progressive shock begins" },
    { label: "6. IRREVERSIBLE SHOCK", text: ">40–45% blood volume lost → CO & BP → 0\nCell membrane failure, ion pump failure\nMyocardial depression (MDF release)\nMulti-organ dysfunction syndrome (MODS)" },
  ];

  const cols = 3, rows = 2;
  steps.forEach((s, i) => {
    const col = i % cols;
    const row = Math.floor(i / cols);
    const x = 0.3 + col * 4.3;
    const y = 1.3 + row * 2.9;
    // Arrow between boxes in same row
    if (col < cols - 1) {
      slide.addShape(pres.ShapeType.rect, { x: x + 4.05, y: y + 1.0, w: 0.25, h: 0.07, fill: { color: ACCENT_GOLD } });
    }
    slide.addShape(pres.ShapeType.roundRect, {
      x, y, w: 4.0, h: 2.7,
      fill: { color: i < 3 ? "1C2E4A" : "2D1515" },
      line: { color: i < 3 ? ACCENT_GOLD : CRIMSON, pt: 1.5 },
      rectRadius: 0.1,
    });
    slide.addShape(pres.ShapeType.rect, { x, y, w: 4.0, h: 0.38, fill: { color: i < 3 ? MID_BLUE : BLOOD_RED }, line: { color: i < 3 ? MID_BLUE : BLOOD_RED } });
    slide.addText(s.label, {
      x: x + 0.1, y: y + 0.04, w: 3.8, h: 0.3,
      fontSize: 11, bold: true, color: WHITE, fontFace: "Calibri",
    });
    slide.addText(s.text, {
      x: x + 0.1, y: y + 0.45, w: 3.8, h: 2.1,
      fontSize: 11, color: BODY_TEXT, fontFace: "Calibri", valign: "top",
    });
  });

  // Downward arrow between rows
  slide.addShape(pres.ShapeType.rect, { x: 6.45, y: 4.05, w: 0.07, h: 0.3, fill: { color: ACCENT_GOLD } });
}

// ─────────────────────────────────────────────────────────────────
// SLIDE 4: PATHOPHYSIOLOGY PART 2 — ORGAN RESPONSES
// ─────────────────────────────────────────────────────────────────
{
  const slide = pres.addSlide();
  addSlideBackground(slide, DARK_SLATE);
  addTitle(slide, "Pathophysiology — Part 2: Organ-Specific Responses",
    "Mulholland & Greenfield's Surgery | Sabiston Textbook of Surgery");

  // Organ columns
  const organs = [
    { name: "CARDIOVASCULAR", color: CRIMSON, items: ["↑ HR, ↑ SVR via SNS activation", "Coronary + cerebral flow preserved via autoregulation (BP >70 mmHg)", "'Last stand': CNS ischemic response at BP <50 mmHg", "Progressive myocardial depression with MDF release", "Eventual cardiac arrest in irreversible shock"] },
    { name: "RENAL", color: "1565C0", items: ["SNS → afferent arteriole constriction", "↓ GFR → oliguria (urine <0.5 mL/kg/hr)", "Angiotensin II + ADH → avid sodium & water retention", "Prolonged ischemia → Acute Tubular Necrosis (ATN)", "Urine Na <20 mEq/L, osmolality >400 mOsm/kg in prerenal state", "FENa <1% distinguishes prerenal from ATN"] },
    { name: "PULMONARY", color: "6A1A5A", items: ["First organ to fail in progressive shock", "Inflammatory mediators from hypoperfused tissues", "ARDS: acute lung injury triggered by ischemia-reperfusion", "High-mortality complication of unresuscitated shock", "Increased vascular permeability → pulmonary edema"] },
    { name: "HEPATIC", color: "4A6A1A", items: ["Not overtly ischemic early", "Releases acute-phase reactants", "Continued shock → hepatic necrosis → ↑ AST/ALT", "↓ Synthesis of coagulation factors → coagulopathy", "Loss of glycogen stores → hypoglycemia in severe cases"] },
    { name: "GASTROINTESTINAL", color: "8A5200", items: ["Gut ischemia → mucosal barrier failure", "Bacterial translocation from gut lumen", "Amplifies systemic inflammatory response (SIRS)", "GI hypoperfusion is both cause and consequence in GI bleeding shock", "Mesenteric vasoconstriction worsens mucosal ischemia"] },
    { name: "COAGULATION", color: "5D1F1F", items: ["Consumption coagulopathy (DIC in severe cases)", "Acidosis + hypothermia → coagulation enzyme dysfunction", "'Lethal triad': acidosis + hypothermia + coagulopathy", "Platelet dysfunction with massive blood loss", "1:1:1 pRBC:FFP:platelets in massive transfusion protocol"] },
  ];

  organs.forEach((o, i) => {
    const col = i % 3;
    const row = Math.floor(i / 3);
    const x = 0.3 + col * 4.3;
    const y = 1.3 + row * 2.9;
    slide.addShape(pres.ShapeType.roundRect, {
      x, y, w: 4.0, h: 2.7,
      fill: { color: DEEP_NAVY },
      line: { color: o.color, pt: 2 },
      rectRadius: 0.08,
    });
    slide.addShape(pres.ShapeType.rect, { x, y, w: 4.0, h: 0.35, fill: { color: o.color }, line: { color: o.color } });
    slide.addText(o.name, {
      x: x + 0.1, y: y + 0.04, w: 3.8, h: 0.27,
      fontSize: 10.5, bold: true, color: WHITE, fontFace: "Calibri",
    });
    addBullets(slide, o.items, x + 0.1, y + 0.42, 3.8, 2.2, 10.5, BODY_TEXT, false, 12);
  });
}

// ─────────────────────────────────────────────────────────────────
// SLIDE 5: ATLS HEMORRHAGIC SHOCK CLASSIFICATION
// ─────────────────────────────────────────────────────────────────
{
  const slide = pres.addSlide();
  addSlideBackground(slide, DARK_SLATE);
  addTitle(slide, "ATLS Classification of Hemorrhagic Shock",
    "ACS ATLS | Mulholland & Greenfield's Surgery | Sabiston Textbook of Surgery");

  // Table header
  const cols_w = [1.5, 1.9, 1.9, 1.9, 1.9, 1.9];
  const startX = 0.27;
  const startY = 1.35;
  const headers = ["Parameter", "Class I", "Class II", "Class III", "Class IV", "Irreversible"];
  const headerColors = ["2C2C2C", "155724", "856404", BLOOD_RED, DARK_RED, "4A0000"];
  headers.forEach((h, i) => {
    const x = startX + cols_w.slice(0, i).reduce((a, b) => a + b, 0);
    slide.addShape(pres.ShapeType.rect, { x, y: startY, w: cols_w[i], h: 0.42, fill: { color: headerColors[i] }, line: { color: "111111", pt: 0.5 } });
    slide.addText(h, { x: x + 0.05, y: startY + 0.06, w: cols_w[i] - 0.1, h: 0.3, fontSize: 11, bold: true, color: WHITE, fontFace: "Calibri", align: "center" });
  });

  const rows = [
    ["Blood Loss (%)", "Up to 15%", "15–30%", "30–40%", ">40%", ">50%"],
    ["Volume (mL)*", "<750 mL", "800–1500", "1500–2000", ">2000", "Exsanguinating"],
    ["Heart Rate", "<100 bpm", "100–120", "120–140", ">140", "Bradycardia/0"],
    ["Blood Pressure", "Normal", "Normal/↓", "↓ Systolic", "Very Low", "Unmeasurable"],
    ["Pulse Pressure", "Normal/↑", "↓", "↓", "↓↓", "Absent"],
    ["Resp Rate", "14–20", "20–30", "30–40", ">35", "Agonal"],
    ["Urine Output", ">30 mL/hr", "20–30", "5–15", "Negligible", "None"],
    ["Mental Status", "Slightly anxious", "Anxious", "Confused/combative", "Lethargic/obtunded", "Unresponsive"],
    ["Skin", "Normal, warm", "Pale, cool", "Pale, cold, clammy", "Cold, mottled", "Mottled/cyanosed"],
    ["Capillary Refill", "Normal", "Delayed", "Markedly delayed", "Absent", "Absent"],
    ["Resuscitation", "Crystalloid only", "Crystalloid ± blood", "Blood + crystalloid", "Immediate transfusion", "MTP + surgical control"],
  ];

  const rowColors = ["1A2A3A", "182030", "1A2A3A", "182030", "1A2A3A", "182030", "1A2A3A", "182030", "1A2A3A", "182030", "1A2A3A"];
  const highlightCells = [[3, 5], [4, 5], [5, 5]]; // highlight class IV and irreversible cells

  rows.forEach((row, ri) => {
    row.forEach((cell, ci) => {
      const x = startX + cols_w.slice(0, ci).reduce((a, b) => a + b, 0);
      const y = startY + 0.42 + ri * 0.49;
      const isHighlighted = ci >= 3;
      const fillColor = ci === 0 ? MID_BLUE : (ci >= 4 ? (ci === 5 ? "3A0000" : "2A0F0F") : rowColors[ri]);
      slide.addShape(pres.ShapeType.rect, { x, y, w: cols_w[ci], h: 0.47, fill: { color: fillColor }, line: { color: "111111", pt: 0.5 } });
      slide.addText(cell, {
        x: x + 0.05, y: y + 0.06, w: cols_w[ci] - 0.1, h: 0.35,
        fontSize: 10, color: ci >= 3 ? (ci === 5 ? ACCENT_GOLD : LIGHT_GREY) : (ci === 0 ? WHITE : BODY_TEXT),
        bold: ci === 0 || ci >= 4, fontFace: "Calibri", align: "center",
      });
    });
  });

  // Footer note
  slide.addText("*Estimated for 70 kg adult. Blood volume ≈ 7% of ideal body weight (~4,900 mL). Individual variation due to age, comorbidities, beta-blockers.", {
    x: 0.27, y: 7.0, w: 13.0, h: 0.3,
    fontSize: 9, color: LIGHT_GREY, italic: true, fontFace: "Calibri",
  });
}

// ─────────────────────────────────────────────────────────────────
// SLIDE 6: SIGNS & SYMPTOMS
// ─────────────────────────────────────────────────────────────────
{
  const slide = pres.addSlide();
  addSlideBackground(slide, DARK_SLATE);
  addTitle(slide, "Clinical Signs & Symptoms",
    "GI Bleeding + Hypovolemic Shock: What to Look For");

  // Left: GI-specific symptoms
  slide.addShape(pres.ShapeType.rect, { x: 0.3, y: 1.3, w: 4.0, h: 5.8, fill: { color: "1E1E35" }, line: { color: ACCENT_GOLD, pt: 1.5 } });
  addSectionLabel(slide, "GI BLEEDING SYMPTOMS", 0.3, 1.3, 4.0, "333370");
  const giSx = [
    "Hematemesis: bright red blood (active/ongoing bleeding)",
    "Coffee-ground emesis: old, oxidized blood (slower bleed)",
    "Melena: black, tarry, foul-smelling stool (≥50 mL blood)",
    "Hematochezia: bright red blood per rectum (usually LGIB; massive UGIB if hemodynamically unstable)",
    "Abdominal pain / epigastric distress",
    "Nausea, vomiting (may precede Mallory-Weiss tear)",
    "History: NSAID/aspirin use, alcohol, cirrhosis, prior GI bleed",
  ];
  addBullets(slide, giSx, 0.45, 1.75, 3.7, 5.1, 11.5, BODY_TEXT);

  // Middle: Hemodynamic symptoms
  slide.addShape(pres.ShapeType.rect, { x: 4.65, y: 1.3, w: 4.0, h: 5.8, fill: { color: "2D1515" }, line: { color: CRIMSON, pt: 1.5 } });
  addSectionLabel(slide, "HEMODYNAMIC SYMPTOMS", 4.65, 1.3, 4.0, BLOOD_RED);
  const hemoSx = [
    "Tachycardia: earliest hemodynamic sign (HR >100)",
    "Hypotension: SBP <90 mmHg (late sign — compensated initially)",
    "Narrow pulse pressure (↑ diastolic from adrenergic discharge)",
    "Orthostatic hypotension: ↓ SBP >20 mmHg on standing",
    "Tachypnea: respiratory compensation for acidosis",
    "Oliguria: <0.5 mL/kg/hr (reflects ↓ renal perfusion)",
    "Thirst, weakness, dizziness, presyncope/syncope",
  ];
  addBullets(slide, hemoSx, 4.8, 1.75, 3.7, 5.1, 11.5, BODY_TEXT);

  // Right: Physical exam findings
  slide.addShape(pres.ShapeType.rect, { x: 9.0, y: 1.3, w: 4.0, h: 5.8, fill: { color: "1A2A1A" }, line: { color: "4CAF50", pt: 1.5 } });
  addSectionLabel(slide, "PHYSICAL EXAMINATION", 9.0, 1.3, 4.0, "2E7D32");
  const examFindings = [
    "Pallor: skin, conjunctiva, nail beds",
    "Cold, clammy skin (peripheral vasoconstriction)",
    "Delayed capillary refill (>2 seconds)",
    "Weak, rapid, thready pulse",
    "Mottling of extremities (advanced shock)",
    "Altered mental status: anxiety → confusion → obtundation → coma",
    "Abdominal tenderness (peritonitis if perforation)",
    "Rectal exam: melena, bright blood, or clots on glove",
    "Stigmata of portal hypertension: spider angiomata, caput medusae, splenomegaly, ascites (varices likely)",
    "Signs of liver disease: jaundice, asterixis, gynecomastia",
  ];
  addBullets(slide, examFindings, 9.15, 1.75, 3.7, 5.1, 11, BODY_TEXT);
}

// ─────────────────────────────────────────────────────────────────
// SLIDE 7: DIAGNOSIS — LABS & IMAGING
// ─────────────────────────────────────────────────────────────────
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  const slide = pres.addSlide();
  addSlideBackground(slide, DARK_SLATE);
  addTitle(slide, "Diagnosis: Laboratory & Imaging Workup",
    "Sabiston Textbook of Surgery | Rosen's Emergency Medicine | Sleisenger & Fordtran's");

  // Lab panel
  slide.addShape(pres.ShapeType.rect, { x: 0.3, y: 1.3, w: 6.1, h: 5.8, fill: { color: "161E2E" }, line: { color: ACCENT_GOLD, pt: 1.5 } });
  addSectionLabel(slide, "LABORATORY INVESTIGATIONS", 0.3, 1.3, 6.1, "1A4A7A");

  const labGroups = [
    { heading: "CBC", items: ["Hemoglobin/Hematocrit — may be initially normal (hemodilution lags)", "Platelets — thrombocytopenia in cirrhosis, consumption in DIC", "WBC — leukocytosis with stress/infection"] },
    { heading: "Coagulation", items: ["PT/INR — prolonged in liver disease/coagulopathy", "aPTT", "Fibrinogen — target >100 mg/dL in active bleeding"] },
    { heading: "Metabolic", items: ["BMP/BUN:Cr ratio >30 strongly suggests UGIB (LR 7.5)", "Lactate — elevated (>2 mmol/L) indicates tissue hypoperfusion", "Arterial Blood Gas — metabolic acidosis (↓ pH, ↓ HCO3)", "Base deficit — correlates with severity of hemorrhage"] },
    { heading: "Liver Function", items: ["AST/ALT — hepatic ischemia or primary liver disease", "Albumin, bilirubin — cirrhosis assessment", "Ammonia — hepatic encephalopathy if cirrhosis"] },
    { heading: "Blood Bank", items: ["Type and Screen / Crossmatch", "TEG/ROTEM — dynamic clot testing for massive transfusion guidance"] },
  ];

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  labGroups.forEach(g => {
    slide.addText(g.heading, {
      x: 0.45, y: yPos, w: 5.8, h: 0.28,
      fontSize: 11, bold: true, color: ACCENT_GOLD, fontFace: "Calibri",
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    g.items.forEach(item => {
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        x: 0.55, y: yPos, w: 5.7, h: 0.28,
        fontSize: 10.5, color: BODY_TEXT, fontFace: "Calibri",
      });
      yPos += 0.28;
    });
    yPos += 0.1;
  });

  // Imaging panel
  slide.addShape(pres.ShapeType.rect, { x: 6.8, y: 1.3, w: 6.2, h: 2.7, fill: { color: "161E2E" }, line: { color: ACCENT_GOLD, pt: 1.5 } });
  addSectionLabel(slide, "IMAGING STUDIES", 6.8, 1.3, 6.2, "1A4A7A");
  const imagingItems = [
    "CT Angiography (CTA): first-line for hemodynamically stable LGIB; detects bleeding >0.3–0.5 mL/min; identifies vascular anomalies; flat IVC sign → shock",
    "Technetium-99m RBC Scintigraphy: detects bleeding >0.1 mL/min; identifies intermittent/slow bleed; localizes source before angiography",
    "Conventional Angiography: therapeutic (embolization) and diagnostic; requires >0.5 mL/min active bleed",
    "CXR/AXR: exclude perforation (free air), obstruction",
    "Bedside FAST/POCUS: assess IVC collapsibility (fluid responsiveness), LV function in shock",
  ];
  addBullets(slide, imagingItems, 6.95, 1.75, 5.9, 2.2, 10.5, BODY_TEXT);

  // Risk scoring
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  addSectionLabel(slide, "RISK STRATIFICATION SCORES", 6.8, 4.2, 6.2, BLOOD_RED);
  const scoreItems = [
    "Glasgow-Blatchford Score (GBS): pre-endoscopy risk; predicts need for intervention; BUN, Hb, SBP, HR, melena, syncope, liver disease, cardiac failure",
    "Rockford Score (post-endoscopy): rebleeding risk from endoscopic findings",
    "AIMS65: Albumin <3, INR >1.5, Altered mental status, SBP <90, Age >65 — predicts inpatient mortality",
    "Shock Index (HR/SBP): >1.0 = significant hemorrhage; >1.5 = massive hemorrhage requiring transfusion",
    "Revised Trauma Score / ATLS Class: used for triaging hemorrhagic shock severity",
  ];
  addBullets(slide, scoreItems, 6.95, 4.65, 5.9, 2.35, 10.5, BODY_TEXT);
}

// ─────────────────────────────────────────────────────────────────
// SLIDE 8: ENDOSCOPY (DIAGNOSTIC & THERAPEUTIC)
// ─────────────────────────────────────────────────────────────────
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  addSlideBackground(slide, DARK_SLATE);
  addTitle(slide, "Endoscopy: The Cornerstone of GI Bleeding Management",
    "Rosen's Emergency Medicine | Sabiston Textbook of Surgery | Sleisenger & Fordtran's");

  // Image — endoscopy GI bleeding
  if (images[1] && !images[1].error) {
    slide.addImage({ data: images[1].base64, x: 0.3, y: 1.3, w: 4.8, h: 3.6 });
  }
  slide.addText("Gastroscopy showing upper GI bleeding with angiodysplasia and endoclip hemostasis", {
    x: 0.3, y: 4.95, w: 4.8, h: 0.4,
    fontSize: 9, color: LIGHT_GREY, italic: true, fontFace: "Calibri",
  });

  // Right panel: endoscopy details
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  addSectionLabel(slide, "ESOPHAGOGASTRODUODENOSCOPY (EGD) — UPPER GI BLEEDING", 5.5, 1.3, 7.5, MID_BLUE);

  const endoGroups = [
    { heading: "Timing", items: ["Urgent EGD within 12–24 hours for hemodynamically stable UGIB", "Immediate EGD (<12 h) for unstable patients after initial resuscitation", "Elective intubation may be needed for ongoing hematemesis / altered mental status", "Avoid routine NG lavage — does not improve outcomes"] },
    { heading: "Forrest Classification (Ulcer Bleeding)", items: ["Ia: Spurting vessel → high risk; immediate therapy", "Ib: Oozing vessel → high risk; therapy required", "IIa: Non-bleeding visible vessel → intermediate; treat endoscopically", "IIb: Adherent clot → intermediate risk", "IIc: Flat pigmented spot / III: Clean base → low risk; no endoscopic therapy"] },
    { heading: "Endoscopic Hemostatic Techniques", items: ["Injection: epinephrine (vasoconstriction) — always combine with second modality", "Thermal coagulation: bipolar, heater probe, APC", "Mechanical: endoclips, over-the-scope clips (OTSC), bands (varices)", "Combination therapy superior to single-modality", "Hemospray/TC-325: powder agent for diffuse/refractory bleeding"] },
    { heading: "Colonoscopy (LGIB)", items: ["Urgent colonoscopy within 24 h after bowel prep for hemodynamically stable LGIB", "Injection, clips, thermal therapy for diverticular bleeding, angiodysplasia"] },
  ];

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  endoGroups.forEach(g => {
    slide.addText(g.heading, {
      x: 5.65, y: yPos, w: 7.2, h: 0.28,
      fontSize: 11, bold: true, color: ACCENT_GOLD, fontFace: "Calibri",
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    yPos += 0.3;
    g.items.forEach(item => {
      slide.addText("• " + item, {
        x: 5.75, y: yPos, w: 7.1, h: 0.28,
        fontSize: 10.5, color: BODY_TEXT, fontFace: "Calibri",
      });
      yPos += 0.28;
    });
    yPos += 0.1;
  });
}

// ─────────────────────────────────────────────────────────────────
// SLIDE 9: TREATMENT — STEP-BY-STEP RESUSCITATION
// ─────────────────────────────────────────────────────────────────
{
  const slide = pres.addSlide();
  addSlideBackground(slide, DARK_SLATE);
  addTitle(slide, "Step-by-Step Treatment: Initial Resuscitation",
    "Sabiston Textbook of Surgery | Rosen's Emergency Medicine | Mulholland & Greenfield's Surgery");

  const steps = [
    {
      num: "STEP 1", label: "AIRWAY & VASCULAR ACCESS",
      items: ["Secure airway: elective intubation if ongoing hematemesis, GCS <8, or respiratory failure", "Two large-bore IV catheters (≥18G) OR large-bore central cordis", "Consider IO access if IV access difficult in extremis", "Supplemental oxygen (100% via NRB mask)"]
    },
    {
      num: "STEP 2", label: "INITIAL FLUID RESUSCITATION",
      items: ["Warmed isotonic crystalloid (NS or LR): 1–2 L IV rapid bolus", "Permissive hypotension strategy in active hemorrhage: target SBP 80–90 mmHg until bleeding controlled", "Avoid excessive crystalloid — worsens coagulopathy, dilutional anemia, and acidosis", "Reassess hemodynamic response after each bolus (HR, BP, urine output, lactate)"]
    },
    {
      num: "STEP 3", label: "BLOOD PRODUCT TRANSFUSION",
      items: ["pRBC transfusion: trigger Hb <7 g/dL (restrictive strategy) in stable; <9 g/dL in active/unstable bleeding", "Do NOT delay transfusion pending labs in active ongoing hemorrhage", "Massive Transfusion Protocol (MTP): 1:1:1 ratio pRBC:FFP:Platelets", "Whole blood (if available): may be superior to component therapy in hemorrhagic shock", "Cryoprecipitate: 1 unit/10 kg if fibrinogen <100–150 mg/dL"]
    },
    {
      num: "STEP 4", label: "PHARMACOLOGICAL THERAPY",
      items: ["Tranexamic Acid (TXA): 1g IV over 10 min if within 3 hours of onset — reduces mortality in hemorrhagic shock", "PPI therapy: IV pantoprazole/esomeprazole (bolus + infusion) — reduces rebleeding in peptic ulcer disease", "Somatostatin analogues (octreotide): reduces portal pressure in variceal bleeding", "Vasopressin / Terlipressin: variceal bleeding; also for vasopressin-deficient state in refractory shock", "Vitamin K (oral/IV) if coagulopathy due to nutritional/liver causes", "Avoid ACEIs, ARBs, beta-blockers in hypotensive cirrhotic patients"]
    },
  ];

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    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = 0.3 + col * 6.4;
    const y = 1.3 + row * 2.9;
    slide.addShape(pres.ShapeType.roundRect, {
      x, y, w: 6.1, h: 2.7,
      fill: { color: DEEP_NAVY },
      line: { color: stepColors[i], pt: 2 },
      rectRadius: 0.1,
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    // Step number badge
    slide.addShape(pres.ShapeType.roundRect, {
      x: x + 0.1, y: y + 0.1, w: 1.1, h: 0.35,
      fill: { color: stepColors[i] }, line: { color: stepColors[i] }, rectRadius: 0.08,
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    slide.addText(s.label, {
      x: x + 1.3, y: y + 0.13, w: 4.7, h: 0.32,
      fontSize: 11, bold: true, color: WHITE, fontFace: "Calibri",
    });
    addBullets(slide, s.items, x + 0.15, y + 0.52, 5.8, 2.1, 10.5, BODY_TEXT, false, 12);
  });
}

// ─────────────────────────────────────────────────────────────────
// SLIDE 10: TREATMENT — DEFINITIVE & SURGICAL
// ─────────────────────────────────────────────────────────────────
{
  const slide = pres.addSlide();
  addSlideBackground(slide, DARK_SLATE);
  addTitle(slide, "Step-by-Step Treatment: Definitive Hemorrhage Control",
    "Sabiston Textbook of Surgery | Rosen's Emergency Medicine | Mulholland & Greenfield's Surgery");

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    {
      num: "STEP 5", label: "ENDOSCOPIC HEMORRHAGE CONTROL",
      items: ["Urgent EGD within 12–24 h for UGIB; within 24 h colonoscopy for LGIB", "Combination endoscopic therapy preferred (injection + thermal/mechanical)", "Forrest Class Ia/Ib/IIa: definitive endoscopic hemostasis", "Variceal banding (EVL) preferred over sclerotherapy for esophageal varices", "Repeat endoscopy at 24 h for high-risk stigmata", "Second-look endoscopy for hemostasis failure"]
    },
    {
      num: "STEP 6", label: "INTERVENTIONAL RADIOLOGY",
      items: ["Transcatheter angiographic embolization: for ongoing LGIB, or UGIB failing endoscopy", "Highly effective: 90%+ technical success for arterial bleeding", "Preferred over surgery in high-risk surgical candidates", "TIPS (Transjugular Intrahepatic Portosystemic Shunt): for refractory variceal bleeding", "CT angiography to localize before interventional radiology"]
    },
    {
      num: "STEP 7", label: "SURGICAL INTERVENTION",
      items: ["Indications: continued hemodynamic instability despite resuscitation, failure of endoscopic & IR therapy, life-threatening hemorrhage (Class IV)", "Emergency laparotomy or laparoscopy guided by preoperative localization", "Damage control surgery: abbreviated initial procedure → ICU resuscitation → definitive repair", "Specific procedures: oversewing ulcer, partial gastrectomy, colonic resection, vascular control", "Mandatory with uncontrolled hemorrhage: SBP <70 despite maximum resuscitation"]
    },
    {
      num: "STEP 8", label: "ICU MONITORING & ENDPOINTS",
      items: ["Admit to ICU: all unstable patients, active bleeding, transfusion requirement", "Resuscitation endpoints: lactate clearance (<2 mmol/L), urine output >0.5 mL/kg/hr, MAP >65 mmHg, base deficit correction", "Monitor: continuous ECG, arterial line (IBP), CVP, serial ABG, lactate, Hb", "TEG/ROTEM guided transfusion in ongoing hemorrhage", "Treat 'lethal triad': correct acidosis (bicarb/THAM), hypothermia (warming blankets, warmed fluids), coagulopathy (MTP)"]
    },
  ];

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    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = 0.3 + col * 6.4;
    const y = 1.3 + row * 2.9;
    slide.addShape(pres.ShapeType.roundRect, {
      x, y, w: 6.1, h: 2.7,
      fill: { color: DEEP_NAVY },
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    slide.addShape(pres.ShapeType.roundRect, {
      x: x + 0.1, y: y + 0.1, w: 1.1, h: 0.35,
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      fontSize: 11, bold: true, color: WHITE, fontFace: "Calibri",
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    addBullets(slide, s.items, x + 0.15, y + 0.52, 5.8, 2.1, 10.5, BODY_TEXT, false, 12);
  });
}

// ─────────────────────────────────────────────────────────────────
// SLIDE 11: VARICEAL BLEEDING SPECIAL CONSIDERATIONS
// ─────────────────────────────────────────────────────────────────
{
  const slide = pres.addSlide();
  addSlideBackground(slide, DARK_SLATE);
  addTitle(slide, "Special Scenario: Variceal Bleeding & Cirrhotic Patient",
    "Rosen's Emergency Medicine | Sleisenger & Fordtran's | GOLDMAN-CECIL MEDICINE");

  // Pathophysiology of varices
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  addSectionLabel(slide, "PATHOPHYSIOLOGY OF VARICES", 0.3, 1.3, 4.0, "5A1A8A");
  const varPath = [
    "Portal hypertension (portal pressure >10–12 mmHg): drives varix formation",
    "Cirrhosis → ↑ hepatic vascular resistance → portal HTN",
    "Collateral channels form at gastroesophageal junction (varices)",
    "Varix rupture: wall tension exceeds threshold (LaPlace's law)",
    "Initial bleeding often massive and life-threatening",
    "Coagulopathy + thrombocytopenia in cirrhosis worsens hemorrhage",
    "Mortality: 10–15% per episode; 60% rebleed within 1 year without treatment",
    "MAP is independent predictor of mortality in cirrhosis — maintain carefully",
  ];
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  // Management
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  addSectionLabel(slide, "VARICEAL HEMORRHAGE MANAGEMENT", 4.65, 1.3, 4.0, "2E7D32");
  const varMgmt = [
    "Resuscitation: IV access, blood products (pRBC, FFP, platelets)",
    "Target Hb 7–8 g/dL (avoid over-transfusion — worsens portal pressure)",
    "Terlipressin or Octreotide (IV infusion): ↓ portal pressure; start immediately",
    "IV antibiotics (ceftriaxone or norfloxacin): mandatory — reduces infection risk and mortality",
    "Urgent EGD: endoscopic variceal ligation (EVL) — gold standard",
    "Sengstaken-Blakemore tube: temporary tamponade bridge to definitive therapy",
    "TIPS: refractory variceal bleeding, Child-Pugh B/C; reduces portal pressure",
    "Avoid beta-blockers, ACEIs, ARBs in acute hemorrhage (↓ MAP)",
    "Primary prophylaxis: propranolol/carvedilol; secondary prophylaxis: EVL + NSBB",
  ];
  addBullets(slide, varMgmt, 4.8, 1.75, 3.7, 5.1, 11, BODY_TEXT);

  // Coagulopathy box
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  addSectionLabel(slide, "COAGULOPATHY IN CIRRHOSIS", 9.0, 1.3, 4.0, BLOOD_RED);
  const coag = [
    "Thrombocytopenia → target platelets >50,000/mm³",
    "INR/PT elevated → but standard dosing of FFP not evidence-based",
    "Cryoprecipitate (1U/10 kg) if fibrinogen <100 mg/dL",
    "Vitamin K (PO 10–20 mEq q6–12h) for nutritional/GI losses",
    "TEG/ROTEM: more accurate clotting assessment in cirrhosis than standard PT/INR",
  ];
  addBullets(slide, coag, 9.15, 1.75, 3.7, 2.2, 10.5, BODY_TEXT);

  // Encephalopathy box
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  addSectionLabel(slide, "HEPATIC ENCEPHALOPATHY", 9.0, 4.2, 4.0, "2E7D32");
  const enceph = [
    "Blood in GI tract → ↑ gut ammonia production → encephalopathy",
    "Risk increases with severity of bleeding",
    "Lactulose: first-line to reduce ammonia absorption",
    "Rifaximin: non-absorbable antibiotic; reduces gut bacterial ammonia production",
    "Monitor grade (I–IV): mild confusion → coma",
    "Airway protection if Grade III–IV encephalopathy",
  ];
  addBullets(slide, enceph, 9.15, 4.65, 3.7, 2.35, 10.5, BODY_TEXT);
}

// ─────────────────────────────────────────────────────────────────
// SLIDE 12: CT IMAGING — SHOCK FINDINGS
// ─────────────────────────────────────────────────────────────────
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  addSlideBackground(slide, DARK_SLATE);
  addTitle(slide, "Imaging in Hypovolemic Shock & GI Bleeding",
    "CT Angiography | Nuclear Medicine | Radiology of Shock");

  if (images[2] && !images[2].error) {
    slide.addImage({ data: images[2].base64, x: 0.3, y: 1.3, w: 5.5, h: 4.1 });
    slide.addText("CT: Characteristic IVC collapse patterns in hypovolemic shock (A: slit-like IVC, B: small aorta in traumatic shock, C: flat IVC with ascites, D: IVC halo sign)", {
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      fontSize: 9, color: LIGHT_GREY, italic: true, fontFace: "Calibri", wrap: true,
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  slide.addShape(pres.ShapeType.rect, { x: 6.2, y: 1.3, w: 6.8, h: 5.8, fill: { color: "161E2E" }, line: { color: ACCENT_GOLD, pt: 1.5 } });
  addSectionLabel(slide, "KEY IMAGING FINDINGS IN SHOCK + GI BLEEDING", 6.2, 1.3, 6.8, MID_BLUE);

  const imgDetails = [
    { heading: "CT Shock Signs (CECT)", items: ["Flat/slit IVC: hallmark of hypovolemia (IVC diameter <9 mm, collapsibility >50%)", "Small aortic calibre: loss of intravascular volume", "'Halo sign' around IVC: peri-vascular edema from endothelial leak", "Hypodense rings around vessels: plasma extravasation", "Shock bowel: diffuse bowel wall thickening, mucosal enhancement, ascites"] },
    { heading: "CT Angiography (GI Bleed)", items: ["Active extravasation: hyperattenuating blush >85 HU in arterial phase", "Detects bleeding rate as low as 0.3–0.5 mL/min", "Identifies culprit vessel for targeted embolization", "Non-contrast phase: hyperdense intraluminal blood (acute hemorrhage)", "Identifies neoplasm, diverticulosis, vascular malformation"] },
    { heading: "Nuclear Medicine (Tc-99m RBC Scan)", items: ["Most sensitive: detects bleeding >0.1 mL/min", "Ideal for slow / intermittent bleeding", "Dynamic early images (0–30 min): focal tracer extravasation", "Delayed images: tracer follows bowel transit to localize origin", "Not useful for rapid, life-threatening hemorrhage (use CTA)"] },
    { heading: "Bedside POCUS in Shock", items: ["IVC diameter <2 cm + collapsibility >50% → fluid responsive", "'Kissing walls' sign on PSAX: severely depleted LV in profound hypovolemia", "Hyperdynamic LV: compensatory in early shock", "Rule out cardiac tamponade, tension pneumothorax as alternate shock etiology"] },
  ];

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  imgDetails.forEach(g => {
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      fontSize: 11, bold: true, color: ACCENT_GOLD, fontFace: "Calibri",
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    yPos += 0.3;
    g.items.forEach(item => {
      slide.addText("• " + item, {
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        fontSize: 10.5, color: BODY_TEXT, fontFace: "Calibri",
      });
      yPos += 0.28;
    });
    yPos += 0.1;
  });
}

// ─────────────────────────────────────────────────────────────────
// SLIDE 13: COMPLICATIONS & MODS
// ─────────────────────────────────────────────────────────────────
{
  const slide = pres.addSlide();
  addSlideBackground(slide, DARK_SLATE);
  addTitle(slide, "Complications: MODS, Lethal Triad & Secondary Events",
    "Mulholland & Greenfield's Surgery | Sabiston Textbook of Surgery");

  // Lethal Triad
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  addSectionLabel(slide, "THE LETHAL TRIAD OF TRAUMA/HEMORRHAGE", 0.3, 1.3, 4.0, BLOOD_RED);
  slide.addText([
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    { text: " (pH <7.35, lactic acidosis, base deficit >6)", options: { color: BODY_TEXT } },
    { text: "\n• Impairs enzyme function, coagulation cascade, myocardial contractility\n\n", options: { color: BODY_TEXT } },
    { text: "Hypothermia", options: { bold: true, color: ACCENT_GOLD } },
    { text: " (core temp <35°C)\n• Coagulation enzyme dysfunction\n• Platelet dysfunction, cardiac arrhythmias\n\n", options: { color: BODY_TEXT } },
    { text: "Coagulopathy", options: { bold: true, color: ACCENT_GOLD } },
    { text: "\n• Consumption of clotting factors\n• DIC in extreme cases\n• Dilutional with crystalloid overload", options: { color: BODY_TEXT } },
  ], { x: 0.45, y: 1.75, w: 3.7, h: 2.2, fontSize: 10.5, fontFace: "Calibri", valign: "top" });

  // MODS
  slide.addShape(pres.ShapeType.rect, { x: 0.3, y: 4.3, w: 4.0, h: 2.8, fill: { color: "1A2020" }, line: { color: "008080", pt: 2 } });
  addSectionLabel(slide, "MULTI-ORGAN DYSFUNCTION SYNDROME (MODS)", 0.3, 4.3, 4.0, "006060");
  const modsItems = ["Sequential organ failure following prolonged shock", "Lung (ARDS) → Kidney (ATN) → Liver → Gut → Coagulation (DIC)", "Triggered by ischemia-reperfusion injury + systemic inflammation", "MODS carries >50% mortality once ≥3 organs involved", "Prevention: early goal-directed resuscitation, source control"];
  addBullets(slide, modsItems, 0.45, 4.75, 3.7, 2.2, 10.5, BODY_TEXT);

  // Rebleeding risk
  slide.addShape(pres.ShapeType.rect, { x: 4.65, y: 1.3, w: 4.2, h: 5.8, fill: { color: "1A1A30" }, line: { color: ACCENT_GOLD, pt: 1.5 } });
  addSectionLabel(slide, "REBLEEDING RISK FACTORS", 4.65, 1.3, 4.2, MID_BLUE);
  const rebleedItems = [
    "Forrest class Ia/Ib/IIa ulcer stigmata",
    "Ulcer size >2 cm",
    "Posterior duodenal wall ulcer (overlying GDA)",
    "High-risk endoscopic features despite initial hemostasis",
    "Coagulopathy not corrected",
    "Continued NSAID / anticoagulant use",
    "Liver disease / portal hypertension",
    "Recurrent variceal hemorrhage (60% at 1 year without prophylaxis)",
    "Hemodynamic instability at presentation",
    "Multiple comorbidities (ASA ≥3)",
    "PPI infusion reduces rebleeding: 80 mg IV bolus then 8 mg/hr infusion for 72 h",
  ];
  addBullets(slide, rebleedItems, 4.8, 1.78, 3.9, 5.1, 11, BODY_TEXT);

  // Predictors of mortality
  slide.addShape(pres.ShapeType.rect, { x: 9.2, y: 1.3, w: 3.8, h: 5.8, fill: { color: "2A1515" }, line: { color: CRIMSON, pt: 1.5 } });
  addSectionLabel(slide, "MORTALITY PREDICTORS", 9.2, 1.3, 3.8, BLOOD_RED);
  const mortPred = [
    "Shock at presentation (SBP <90)",
    "Age >65 years",
    "Comorbidities: cardiac, hepatic, renal failure",
    "Active bleeding at endoscopy",
    "Rebleeding in hospital",
    "Need for surgery",
    "Coagulopathy: INR >1.5 or fibrinogen <100",
    "Albumin <3 g/dL (AIMS65 score)",
    "Altered mental status",
    "Vasopressor requirement",
    "Lactate >4 mmol/L on admission",
    "Base deficit > -6",
    "Failure to clear lactate within 6 h",
  ];
  addBullets(slide, mortPred, 9.35, 1.75, 3.5, 5.1, 10.5, BODY_TEXT);
}

// ─────────────────────────────────────────────────────────────────
// SLIDE 14: CLINICAL ALGORITHM / FLOWCHART
// ─────────────────────────────────────────────────────────────────
{
  const slide = pres.addSlide();
  addSlideBackground(slide, DEEP_NAVY);
  addTitle(slide, "Clinical Algorithm: GI Bleeding with Hemodynamic Instability",
    "Step-by-Step Approach | Emergency & Surgical Management");

  // Main flow boxes
  const boxes = [
    { x: 5.3, y: 1.3, w: 2.7, h: 0.6, color: BLOOD_RED, text: "PATIENT PRESENTS WITH GI BLEEDING", fontSize: 9, bold: true },
    { x: 5.3, y: 2.1, w: 2.7, h: 0.6, color: MID_BLUE, text: "IMMEDIATE ASSESSMENT\nAirway, Breathing, Circulation (ABC)\nVital signs, Shock Index (HR/SBP)", fontSize: 8.5 },
    { x: 5.3, y: 2.9, w: 2.7, h: 0.6, color: "1A5A2A", text: "HEMODYNAMICALLY STABLE?", fontSize: 10, bold: true },
  ];

  boxes.forEach(b => {
    slide.addShape(pres.ShapeType.roundRect, { x: b.x, y: b.y, w: b.w, h: b.h, fill: { color: b.color }, line: { color: ACCENT_GOLD, pt: 1 }, rectRadius: 0.08 });
    slide.addText(b.text, { x: b.x + 0.08, y: b.y + 0.06, w: b.w - 0.16, h: b.h - 0.12, fontSize: b.fontSize || 9, bold: b.bold || false, color: WHITE, fontFace: "Calibri", align: "center" });
    // Downward connector
    if (b !== boxes[boxes.length - 1]) {
      slide.addShape(pres.ShapeType.rect, { x: b.x + b.w / 2 - 0.03, y: b.y + b.h, w: 0.06, h: 0.1, fill: { color: ACCENT_GOLD } });
    }
  });

  // YES branch (stable) — RIGHT
  const stableX = 9.2;
  slide.addText("YES", { x: 8.15, y: 3.1, w: 0.8, h: 0.25, fontSize: 9, bold: true, color: "#4CAF50", fontFace: "Calibri", align: "center" });
  slide.addShape(pres.ShapeType.rect, { x: 8.0, y: 3.2, w: 1.2, h: 0.06, fill: { color: ACCENT_GOLD } });

  const stableSteps = [
    { text: "NPO + IV Access (2x large bore)\nLabs: CBC, BMP, PT/INR, T&S\nType & Screen" },
    { text: "Risk Stratify:\nGlasgow-Blatchford Score\nAIMS65 Score" },
    { text: "UGIB: EGD within 24 h\nLGIB: Colonoscopy within 24 h\nafter bowel prep" },
    { text: "Low-risk: discharge\nHigh-risk: admit + PPI\nRepeated endoscopy if rebleed" },
  ];
  stableSteps.forEach((s, i) => {
    const y = 2.95 + i * 0.9;
    slide.addShape(pres.ShapeType.roundRect, { x: stableX, y, w: 3.8, h: 0.75, fill: { color: "0F3460" }, line: { color: ACCENT_GOLD, pt: 0.8 }, rectRadius: 0.06 });
    slide.addText(s.text, { x: stableX + 0.1, y: y + 0.07, w: 3.6, h: 0.6, fontSize: 9, color: WHITE, fontFace: "Calibri" });
    if (i < stableSteps.length - 1) slide.addShape(pres.ShapeType.rect, { x: stableX + 1.85, y: y + 0.75, w: 0.05, h: 0.15, fill: { color: ACCENT_GOLD } });
  });

  // NO branch (unstable) — LEFT
  slide.addText("NO", { x: 4.4, y: 3.1, w: 0.75, h: 0.25, fontSize: 9, bold: true, color: CRIMSON, fontFace: "Calibri", align: "center" });
  slide.addShape(pres.ShapeType.rect, { x: 3.9, y: 3.2, w: 1.3, h: 0.06, fill: { color: CRIMSON } });

  const unstableSteps = [
    { text: "ACTIVATE MTP & Resuscitation Team\n2x large-bore IV or cordis, O2, monitor" },
    { text: "Warmed crystalloid bolus 1–2L\npRBC if Hb <7 (or actively bleeding)\nMTP 1:1:1 if massive hemorrhage" },
    { text: "Pharmacology:\nTranexamic Acid (within 3h)\nOctreotide if variceal\nPPI bolus + infusion" },
    { text: "Urgent EGD: UGIB → endoscopic\nhemostasis\nColonoscopy/IR: LGIB" },
    { text: "Failure → IR Embolization\nor Emergency Surgery\n(Damage Control Protocol)" },
  ];
  unstableSteps.forEach((s, i) => {
    const y = 2.95 + i * 0.85;
    slide.addShape(pres.ShapeType.roundRect, { x: 0.3, y, w: 3.5, h: 0.72, fill: { color: "2D1515" }, line: { color: CRIMSON, pt: 0.8 }, rectRadius: 0.06 });
    slide.addText(s.text, { x: 0.4, y: y + 0.07, w: 3.3, h: 0.58, fontSize: 8.5, color: WHITE, fontFace: "Calibri" });
    if (i < unstableSteps.length - 1) slide.addShape(pres.ShapeType.rect, { x: 1.8, y: y + 0.72, w: 0.05, h: 0.13, fill: { color: CRIMSON } });
  });

  // ICU box at bottom center
  slide.addShape(pres.ShapeType.roundRect, { x: 4.0, y: 6.55, w: 5.3, h: 0.7, fill: { color: "1A1A30" }, line: { color: ACCENT_GOLD, pt: 1.5 }, rectRadius: 0.1 });
  slide.addText("ICU MONITORING: Lactate clearance, urine output >0.5 mL/kg/hr, MAP >65 mmHg\nTreat lethal triad: Acidosis + Hypothermia + Coagulopathy", {
    x: 4.1, y: 6.6, w: 5.1, h: 0.6,
    fontSize: 9.5, color: ACCENT_GOLD, bold: true, fontFace: "Calibri", align: "center",
  });
}

// ─────────────────────────────────────────────────────────────────
// SLIDE 15: SUMMARY
// ─────────────────────────────────────────────────────────────────
{
  const slide = pres.addSlide();
  addSlideBackground(slide, DEEP_NAVY);

  // Left dark red panel
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 4.0, h: 7.5, fill: { color: DARK_RED } });
  slide.addText("KEY\nTAKEAWAYS", {
    x: 0.15, y: 2.5, w: 3.7, h: 2.0,
    fontSize: 32, bold: true, color: WHITE, fontFace: "Calibri", align: "center", charSpacing: 2,
  });
  slide.addText("Hypovolemic Shock\nin GI Bleeding", {
    x: 0.15, y: 4.6, w: 3.7, h: 1.0,
    fontSize: 14, color: LIGHT_GOLD, fontFace: "Calibri", align: "center", italic: true,
  });
  slide.addShape(pres.ShapeType.rect, { x: 0.5, y: 4.55, w: 3.0, h: 0.05, fill: { color: ACCENT_GOLD } });

  // Right panel: key takeaways
  const takeaways = [
    "Hypovolemic shock = ↓ intravascular volume → ↓ CO → inadequate perfusion; commonest shock in surgical practice",
    "GI bleeding (peptic ulcer, varices, diverticular, angiodysplasia) is a leading cause of non-traumatic hemorrhagic shock",
    "ATLS Classes I–IV guide resuscitation: >20% blood loss produces shock; >40% is immediately life-threatening",
    "Compensatory mechanisms (SNS, RAAS, ADH) temporarily maintain BP but fail with >30–40% blood loss",
    "Earliest sign: tachycardia. Hypotension is a late sign indicating decompensated shock",
    "BUN:Cr ratio >30 strongly predicts UGIB (LR 7.5); Shock Index (HR/SBP) >1.0 = significant hemorrhage",
    "Resuscitation priorities: airway → IV access → crystalloid bolus → MTP transfusion (1:1:1) → TXA",
    "Restrictive transfusion strategy (Hb trigger <7 g/dL) unless active/ongoing bleeding",
    "PPI IV infusion + Octreotide (varices) + IV antibiotics reduce morbidity and mortality",
    "Urgent EGD within 12–24 h: cornerstone of diagnosis and hemostasis",
    "Failure of endoscopy → IR embolization; failure of IR → surgical hemorrhage control",
    "Lethal triad (acidosis + hypothermia + coagulopathy) must be aggressively reversed",
    "MODS is the terminal pathway: prevent by early, goal-directed resuscitation and source control",
  ];

  takeaways.forEach((t, i) => {
    const col = Math.floor(i / 7);
    const row = i % 7;
    slide.addShape(pres.ShapeType.roundRect, {
      x: 4.3 + col * 4.4, y: 0.45 + row * 0.93, w: 4.2, h: 0.85,
      fill: { color: i % 2 === 0 ? MID_BLUE : "1A2A3A" }, line: { color: ACCENT_GOLD, pt: 0.8 }, rectRadius: 0.06,
    });
    slide.addText([
      { text: String(i + 1) + ".  ", options: { bold: true, color: ACCENT_GOLD } },
      { text: t, options: { color: BODY_TEXT } },
    ], {
      x: 4.4 + col * 4.4, y: 0.5 + row * 0.93, w: 4.0, h: 0.75,
      fontSize: 9.5, fontFace: "Calibri", valign: "middle",
    });
  });

  // Bottom bar
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 7.35, w: 13.33, h: 0.15, fill: { color: CRIMSON } });
  slide.addText("Sources: Guyton & Hall Physiology | Sabiston Textbook of Surgery | Mulholland & Greenfield's Surgery | Rosen's Emergency Medicine | Sleisenger & Fordtran's GI | Goldman-Cecil Medicine", {
    x: 0.3, y: 7.1, w: 13.0, h: 0.22,
    fontSize: 7.5, color: LIGHT_GREY, italic: true, fontFace: "Calibri",
  });
}

// ─────────────────────────────────────────────────────────────────
// WRITE FILE
// ─────────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/hypovolemic-shock-gi/Hypovolemic_Shock_GI_Bleeding.pptx" })
  .then(() => console.log("SUCCESS: Presentation saved!"))
  .catch(e => console.error("ERROR:", e));