epiglottitis swollen epiglottis lateral neck radiograph thumb sign

croup steeple sign subglottic narrowing

Westley croup score components scoring mild moderate severe dexamethasone 0.15 mg/kg nebulised epinephrine guideline

"croup"[MeSH Terms] AND "dexamethasone"

sagittal view larynx anatomy epiglottis vallecula vocal cords subglottic cricoid labelled

"Westley" in /textbooks/9781260019933

acute epiglottitis children management ceftriaxone dose airway intubation Hib rifampin prophylaxis household contacts

acute epiglottitis cherry red swollen epiglottis laryngoscopy

mkdir -p /tmp/workspace/epiglottitis-croup/{assets,output,src} && cd /tmp/workspace/epiglottitis-croup && cat > src/figs.py <<'EOF' import numpy as np, matplotlib matplotlib.use("Agg") import matplotlib.pyplot as plt from matplotlib.patches import Polygon, Ellipse, Rectangle, Circle, FancyArrowPatch try: from scipy.interpolate import PchipInterpolator as P except Exception: P=None TISSUE='#F6E7D8'; MUC='#B5836B'; AIR='#DCEEFA'; CART='#C3D3E4'; PINK='#E9A3A3'; RED='#C0392B'; NAVY='#1F3A5F' ys=np.array([12,8.6,7.4,6.0,5.0,4.4,3.0,2.0,0]) def sm(y,v): yy=np.linspace(0,12,120) if P is not None: f=P(ys[::-1],np.array(v)[::-1]); return yy[::-1],f(yy[::-1]) return yy[::-1],np.interp(yy,ys[::-1],np.array(v)[::-1])[::-1] ANT=[3.6,3.9,4.1,4.3,4.8,4.7,4.6,4.6,4.6]; POST=[6.8,6.6,6.4,6.2,5.9,6.0,6.1,6.1,6.1] CANT=[3.6,3.9,4.1,4.3,4.9,5.05,4.95,4.75,4.6]; CPOST=[6.8,6.6,6.4,6.2,5.8,5.65,5.75,5.95,6.1] def draw(ax,mode='normal',labels=True,fs=9,notes=None): ax.set_xlim(0,11.5); ax.set_ylim(-0.3,12.3); ax.axis('off'); ax.set_aspect('equal') ax.add_patch(Rectangle((2.4,0),5.4,12,fc=TISSUE,ec='none')) ax.add_patch(Ellipse((3.0,10.7),3.6,2.6,fc='#E58E8E',ec=MUC,lw=1)) a=CANT if mode=='croup' else ANT; p=CPOST if mode=='croup' else POST y1,xa=sm(ys,a); y2,xp=sm(ys,p) pts=list(zip(xa,y1))+list(zip(xp[::-1],y2[::-1])) ax.add_patch(Polygon(pts,fc=AIR,ec=MUC,lw=2.2,zorder=3)) if mode=='croup': sy=[5.0,4.4,3.0,2.0] for n,c in ((([4.8,4.7,4.6,4.6]),[4.9,5.05,4.95,4.75]),(([5.9,6.0,6.1,6.1]),[5.8,5.65,5.75,5.95])): ax.add_patch(Polygon(list(zip(n,sy))+list(zip(c[::-1],sy[::-1])),fc=RED,ec='none',zorder=4)) # cartilages ax.add_patch(Ellipse((3.35,8.1),0.55,1.0,fc=CART,ec=MUC,lw=1)); ax.add_patch(Polygon([(3.3,7.2),(4.0,7.0),(4.15,5.4),(3.7,5.0),(3.35,5.6)],fc=CART,ec=MUC,lw=1)) ax.add_patch(Polygon([(4.1,4.85),(4.65,4.75),(4.65,3.9),(4.15,3.9)],fc=CART,ec=MUC,lw=1)) ax.add_patch(Polygon([(6.1,5.5),(6.75,5.5),(6.75,3.8),(6.15,3.8)],fc=CART,ec=MUC,lw=1)) for y in [3.2,2.5,1.8,1.1,0.4]: ax.add_patch(Rectangle((4.0,y-0.15),0.5,0.3,fc=CART,ec=MUC,lw=0.8)) # vocal cords ax.add_patch(Polygon([(4.8,5.18),(5.3,5.0),(4.8,4.82)],fc='#F2F2F2',ec=MUC,lw=1,zorder=5)) ax.add_patch(Polygon([(5.9,5.18),(5.45,5.0),(5.9,4.82)],fc='#F2F2F2',ec=MUC,lw=1,zorder=5)) # arytenoid / AE fold if mode=='epi': ax.add_patch(Ellipse((5.85,6.3),0.9,1.1,fc=RED,ec='#7B241C',lw=1,zorder=6)) else: ax.add_patch(Ellipse((6.05,6.2),0.35,0.55,fc=PINK,ec=MUC,lw=1,zorder=6)) # epiglottis cx=np.array([4.35,4.2,4.3,4.75]); cy=np.array([6.0,6.8,7.6,8.25]) w=1.15 if mode=='epi' else 0.26; sh=0.3 if mode=='epi' else 0 yy=np.linspace(6.0,8.25,30); xx=np.interp(yy,cy,cx)+sh*np.sin(np.linspace(0,np.pi,30)) pol=list(zip(xx-w/2,yy))+list(zip((xx+w/2)[::-1],yy[::-1])) col=RED if mode=='epi' else PINK ax.add_patch(Polygon(pol,fc=col,ec='#7B241C' if mode=='epi' else MUC,lw=1.2,zorder=6)) if mode=='epi': ax.add_patch(Circle((xx[-1],yy[-1]),w/2,fc=col,ec='#7B241C',lw=1.2,zorder=6)) ax.text(2.55,0.1,'ANTERIOR',fontsize=fs-2,color='#555',rotation=90,va='bottom') ax.text(7.6,0.1,'POSTERIOR',fontsize=fs-2,color='#555',rotation=90,va='bottom',ha='right') if labels: L=[('Tongue base',(2.6,10.9),0.1,10.9),('Hyoid bone',(3.2,8.1),0.1,8.9),('Vallecula',(3.95,8.5),0.1,7.9), ('Thyroid cartilage',(3.6,6.2),0.1,6.4),('Cricoid cartilage',(4.4,4.3),0.1,4.3),('Tracheal rings',(4.25,2.5),0.1,2.5)] R=[('Oropharynx',(5.3,10.5),8.2,10.5),('Epiglottis',(4.85,8.0),8.2,8.6),('Aryepiglottic fold /\narytenoid',(6.1,6.3),8.2,6.9), ('Glottis\n(vocal cords)',(5.5,5.0),8.2,5.2),('Subglottis',(5.35,4.0),8.2,3.8),('Trachea',(5.4,1.2),8.2,1.4)] for t,xy,tx,ty in L: ax.annotate(t,xy=xy,xytext=(tx,ty),fontsize=fs,color=NAVY,va='center',ha='left',arrowprops=dict(arrowstyle='-',color='#555',lw=0.8),zorder=9) for t,xy,tx,ty in R: ax.annotate(t,xy=xy,xytext=(tx,ty),fontsize=fs,color=NAVY,va='center',ha='left',arrowprops=dict(arrowstyle='-',color='#555',lw=0.8),zorder=9) if notes: for t,xy,tx,ty in notes: ax.annotate(t,xy=xy,xytext=(tx,ty),fontsize=fs,color='#7B241C',fontweight='bold',va='center',ha='left',arrowprops=dict(arrowstyle='->',color='#7B241C',lw=1.4),zorder=9) def save(fn,mode,size,fs,labels=True,notes=None,title=None): fig,ax=plt.subplots(figsize=size); draw(ax,mode,labels,fs,notes) if title: ax.set_title(title,fontsize=fs+3,color=NAVY,fontweight='bold') fig.savefig(fn,dpi=200,bbox_inches='tight',transparent=False,facecolor='white'); plt.close(fig) A='assets/' save(A+'sag_normal.png','normal',(6.4,7.4),10) save(A+'sag_epi.png','epi',(6.0,6.9),9.5,True,[('Swollen, cherry-red\nepiglottis (thumb shape)',(4.9,8.2),8.2,9.6),('Oedematous AE folds\nnarrow the inlet',(6.0,6.4),8.2,7.4)]) save(A+'sag_croup.png','croup',(6.0,6.9),9.5,True,[('Subglottic oedema\n(steeple narrowing)',(5.0,3.9),8.2,2.6)]) fig,axs=plt.subplots(1,3,figsize=(12.3,5.3)) specs=[('NORMAL AIRWAY','normal',None),('EPIGLOTTITIS: supraglottic','epi',[('Swollen\nepiglottis',(4.9,8.2),8.0,9.8),('Inlet narrowed',(5.9,6.4),8.0,7.2)]),('CROUP: subglottic','croup',[('Subglottic\nnarrowing',(5.0,3.9),8.0,2.4)])] for ax,(t,m,n) in zip(axs,specs): draw(ax,m,False,9,n); ax.set_title(t,fontsize=12,color={'normal':NAVY,'epi':'#B3261E','croup':'#2A6FBB'}[m],fontweight='bold') fig.tight_layout(); fig.savefig(A+'three.png',dpi=200,facecolor='white'); plt.close(fig) # cross-section fig,axs=plt.subplots(1,2,figsize=(8.2,4.4)) for ax,t,lum in zip(axs,['Normal subglottis\n(about 6.5 mm diameter, 18-month-old)','Croup: 1 mm circumferential oedema\n(lumen about 4.5 mm)'],[3.25,2.25]): ax.set_xlim(-5,5); ax.set_ylim(-5,5); ax.set_aspect('equal'); ax.axis('off') ax.add_patch(Circle((0,0),4.4,fc=CART,ec=MUC,lw=1.5)); ax.add_patch(Circle((0,0),3.25,fc='#F0B8B0' if lum<3 else PINK,ec=MUC,lw=1)) if lum<3: ax.add_patch(Circle((0,0),3.25,fc=RED,ec='none',alpha=0.85)) ax.add_patch(Circle((0,0),lum,fc=AIR,ec=MUC,lw=1.5)); ax.set_title(t,fontsize=10,color=NAVY) ax.text(0,0,'air' if lum>3 else 'air\n(area -52%)',ha='center',va='center',fontsize=10,color=NAVY) axs[0].text(0,-4.9,'cricoid ring (rigid) surrounds mucosa',ha='center',fontsize=8,color='#555') fig.tight_layout(); fig.savefig(A+'cross.png',dpi=200,facecolor='white'); plt.close(fig) fig,ax=plt.subplots(figsize=(5.6,3.6)) rr=['0%','10%','25%','50%']; v=[(1-float(x.strip('%'))/100)**-4 for x in rr] b=ax.bar(rr,v,color=['#7FB3D5','#5499C7','#2A6FBB','#B3261E']) for r,val in zip(b,v): ax.text(r.get_x()+r.get_width()/2,val+0.3,f'x{val:.1f}',ha='center',fontsize=10,color=NAVY) ax.set_xlabel('Reduction in airway radius'); ax.set_ylabel('Relative resistance (laminar, 1/r^4)'); ax.spines[['top','right']].set_visible(False) ax.set_title('Small radius loss, large resistance rise',fontsize=11,color=NAVY) fig.tight_layout(); fig.savefig(A+'resist.png',dpi=200,facecolor='white'); plt.close(fig) print('ok') EOF python src/figs.py && python /tmp/skills/shared/scripts/fetch_images.py "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_59f4fa939e89f94d53a67916d488aa01a326681cb52b7a7b2f105a68f116c00a.jpg" "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_57e97979f2d04d6e4b617bd8771263ec99967c0987e0fa40c242ba213bc4ca9b.jpg" "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_623fd8b4b065c691b510c6204aa6bd1ad25e4b4d7bc2cae4dbfe27c0519ec262.jpg" "https://cdn.orris.care/cdss_images/492628ef8cc3d72b6c1a84aa6ccf4d6312d9a9a460e02cfde64bd4385e1d5fa6.png" > assets/imgs.json && python - <<'EOF' import json,base64 d=json.load(open('assets/imgs.json')) names=['epi_xray.jpg','steeple_pmc.jpg','epi_laryngo.jpg','steeple_sb.png'] for n,i in zip(names,d): print(n,i['error']) if i['base64']: open('assets/'+n,'wb').write(base64.b64decode(i['base64'].split('base64,')[1])) EOF ls -la assets

cd /tmp/workspace/epiglottitis-croup && cat > src/build.py <<'EOF' import math, copy from PIL import Image from lxml import etree from pptx import Presentation from pptx.util import Inches, Pt, Emu from pptx.dml.color import RGBColor from pptx.enum.text import PP_ALIGN, MSO_ANCHOR from pptx.enum.shapes import MSO_SHAPE def C(h): return RGBColor.from_string(h.lstrip('#')) NAVY='1F3A5F'; TEAL='0E7C86'; RED='B3261E'; BLUE='2A6FBB'; PURPLE='5B3F8C'; GREY='5F6B7A'; LIGHT='F2F5F9'; AMBER='B26A00'; WHITE='FFFFFF'; DARK='222B36' SEC={'A':(TEAL,'A INTRODUCTION'),'B':(RED,'B EPIGLOTTITIS'),'C':(BLUE,'C CROUP'),'D':(PURPLE,'D SYNTHESIS'),'R':(GREY,'REFERENCES')} prs=Presentation(); prs.slide_width=Inches(13.333); prs.slide_height=Inches(7.5) BL=prs.slide_layouts[6]; A='assets/'; WARN=[]; N=[0] def run_fmt(r,size,color=DARK,bold=False,italic=False): r.font.name='Calibri'; r.font.size=Pt(size); r.font.bold=bold; r.font.italic=italic; r.font.color.rgb=C(color) def est_lines(text,w,size): cpl=max(1,int(w*72/(size*0.50))) return sum(max(1,math.ceil(len(l)/cpl)) for l in text.split('\n')) def text(slide,x,y,w,h,t,size=16,color=DARK,bold=False,align=PP_ALIGN.LEFT,anchor=MSO_ANCHOR.TOP,name=None,italic=False,check=True): tb=slide.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h)); tf=tb.text_frame; tf.word_wrap=True tf.margin_left=tf.margin_right=Inches(0.05); tf.margin_top=tf.margin_bottom=Inches(0.03); tf.vertical_anchor=anchor for i,line in enumerate(t.split('\n')): p=tf.paragraphs[0] if i==0 else tf.add_paragraph(); p.alignment=align r=p.add_run(); r.text=line; run_fmt(r,size,color,bold,italic) if name: tb.name=name if check: need=est_lines(t,w-0.1,size)*size*1.2/72+0.06 if need>h+0.15: WARN.append((N[0],t[:30],round(need,2),h)) return tb def bullets(slide,items,x,y,w,h,size=16,color=DARK,gap=5): tb=slide.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h)); tf=tb.text_frame; tf.word_wrap=True tf.margin_left=tf.margin_right=Inches(0.05); tf.margin_top=Inches(0.03) need=0.1 for i,it in enumerate(items): lvl=0 if isinstance(it,tuple): it,lvl=it p=tf.paragraphs[0] if i==0 else tf.add_paragraph() p.space_after=Pt(gap) sz=size-(2 if lvl else 0) mark='\u2022 ' if lvl==0 else '- ' indent=' '*lvl if '||' in it: a,b=it.split('||',1) r=p.add_run(); r.text=indent+mark+a; run_fmt(r,sz,NAVY,True) r=p.add_run(); r.text=b; run_fmt(r,sz,color) full=indent+mark+a+b else: r=p.add_run(); r.text=indent+mark+it; run_fmt(r,sz,color); full=indent+mark+it need+=est_lines(full,w-0.1,sz)*sz*1.2/72+gap/72 if need>h+0.15: WARN.append((N[0],'bullets '+str(items[0])[:25],round(need,2),h)) return tb def box(slide,x,y,w,h,t,fill=LIGHT,fg=DARK,size=14,bold=False,shape=MSO_SHAPE.ROUNDED_RECTANGLE,align=PP_ALIGN.LEFT,line=None,anchor=MSO_ANCHOR.MIDDLE,name=None): s=slide.shapes.add_shape(shape,Inches(x),Inches(y),Inches(w),Inches(h)) s.fill.solid(); s.fill.fore_color.rgb=C(fill) if line: s.line.color.rgb=C(line); s.line.width=Pt(1.5) else: s.line.fill.background() s.shadow.inherit=False if shape==MSO_SHAPE.ROUNDED_RECTANGLE: s.adjustments[0]=0.08 tf=s.text_frame; tf.word_wrap=True; tf.vertical_anchor=anchor tf.margin_left=tf.margin_right=Inches(0.1); tf.margin_top=tf.margin_bottom=Inches(0.04) for i,l in enumerate(t.split('\n')): p=tf.paragraphs[0] if i==0 else tf.add_paragraph(); p.alignment=align if '||' in l: a,b=l.split('||',1); r=p.add_run(); r.text=a; run_fmt(r,size,fg,True); r=p.add_run(); r.text=b; run_fmt(r,size,fg,bold) else: r=p.add_run(); r.text=l; run_fmt(r,size,fg,bold) need=est_lines(t.replace('||',''),w-0.25,size)*size*1.2/72+0.1 if need>h+0.1: WARN.append((N[0],'box '+t[:25],round(need,2),h)) if name: s.name=name return s def arrow(slide,x,y,w,h,kind='down',color=GREY): shp={'down':MSO_SHAPE.DOWN_ARROW,'right':MSO_SHAPE.RIGHT_ARROW}[kind] s=slide.shapes.add_shape(shp,Inches(x),Inches(y),Inches(w),Inches(h)); s.fill.solid(); s.fill.fore_color.rgb=C(color); s.line.fill.background(); return s def pic(slide,path,x,y,w,h,name=None,caption=None,capsize=10): im=Image.open(path); ar=im.width/im.height if w/h>ar: nh=h; nw=h*ar else: nw=w; nh=w/ar px=x+(w-nw)/2; py=y+(h-nh)/2 p=slide.shapes.add_picture(path,Inches(px),Inches(py),Inches(nw),Inches(nh)) if name: p.name=name if caption: text(slide,x,py+nh+0.02,w,0.5,caption,capsize,GREY,italic=True,align=PP_ALIGN.CENTER,check=False) return p def table(slide,rows,x,y,w,colw,fs=11,hfill=NAVY,hfills=None,firstcol=True,maxh=5.6,zebra=True): nr=len(rows); nc=len(rows[0]); tot=sum(colw); cw=[w*c/tot for c in colw] heights=[] for ri,row in enumerate(rows): m=max(est_lines(c,cw[ci]-0.15,fs) for ci,c in enumerate(row)); heights.append(m*fs*1.18/72+0.1) H=sum(heights) if H>maxh: WARN.append((N[0],'TABLE',round(H,2),maxh)) gs=slide.shapes.add_table(nr,nc,Inches(x),Inches(y),Inches(w),Inches(H)); tb=gs.table tblPr=gs._element.graphic.graphicData.tbl.tblPr; tblPr.set('bandRow','0'); tblPr.set('firstRow','0') for ci in range(nc): tb.columns[ci].width=Inches(cw[ci]) for ri,row in enumerate(rows): tb.rows[ri].height=Inches(heights[ri]) for ci,c in enumerate(row): cell=tb.cell(ri,ci); cell.margin_left=cell.margin_right=Inches(0.06); cell.margin_top=cell.margin_bottom=Inches(0.03) cell.vertical_anchor=MSO_ANCHOR.MIDDLE tf=cell.text_frame; tf.word_wrap=True for li,l in enumerate(c.split('\n')): p=tf.paragraphs[0] if li==0 else tf.add_paragraph(); r=p.add_run(); r.text=l if ri==0: run_fmt(r,fs,WHITE,True) else: run_fmt(r,fs,DARK,bold=(ci==0 and firstcol)) cell.fill.solid() if ri==0: cell.fill.fore_color.rgb=C(hfills[ci] if hfills else hfill) elif ci==0 and firstcol: cell.fill.fore_color.rgb=C('E3EAF2') else: cell.fill.fore_color.rgb=C('FFFFFF' if (ri%2 or not zebra) else 'F5F7FA') return gs def morph(slide): xml=('<mc:AlternateContent xmlns:mc="http://schemas.openxmlformats.org/markup-compatibility/2006" ' 'xmlns:p="http://schemas.openxmlformats.org/presentationml/2006/main">' '<mc:Choice xmlns:p159="http://schemas.microsoft.com/office/powerpoint/2015/09/main" ' 'xmlns:p14="http://schemas.microsoft.com/office/powerpoint/2010/main" Requires="p159">' '<p:transition spd="slow" p14:dur="1200"><p159:morph option="byObject"/></p:transition></mc:Choice>' '<mc:Fallback><p:transition spd="med"><p:fade/></p:transition></mc:Fallback></mc:AlternateContent>') el=etree.fromstring(xml); sld=slide._element cm=sld.find('{http://schemas.openxmlformats.org/presentationml/2006/main}clrMapOvr') if cm is not None: cm.addnext(el) else: sld.append(el) def new(title,sec,source='',notes='',dark=False): N[0]+=1; s=prs.slides.add_slide(BL); col,lab=SEC[sec] if dark: bg=s.background.fill; bg.solid(); bg.fore_color.rgb=C(NAVY) else: ab=s.shapes.add_shape(MSO_SHAPE.RECTANGLE,0,0,Inches(0.22),Inches(7.5)); ab.fill.solid(); ab.fill.fore_color.rgb=C(col); ab.line.fill.background(); ab.name='SideBar' text(s,0.5,0.25,10.2,0.85,title,28,NAVY,True,anchor=MSO_ANCHOR.MIDDLE,name='Title') b=box(s,10.9,0.4,2.15,0.42,lab,col,WHITE,11,True,align=PP_ALIGN.CENTER,name='Badge') ln=s.shapes.add_shape(MSO_SHAPE.RECTANGLE,Inches(0.5),Inches(1.12),Inches(12.4),Inches(0.04)); ln.fill.solid(); ln.fill.fore_color.rgb=C(col); ln.line.fill.background(); ln.name='TitleRule' text(s,0.5,7.08,11.6,0.3,source,9,GREY,name='Footer',check=False) text(s,12.3,7.08,0.7,0.3,str(N[0]),10,GREY,align=PP_ALIGN.RIGHT,name='SlideNo',check=False) if notes: s.notes_slide.notes_text_frame.text=notes morph(s); return s TB='Verified in library textbooks: ' # ---------------- S1 title s=new('', 'A', dark=True, notes='Title slide. Presenter, department and institution placeholders to be completed. Content is built from library textbooks (Scott-Brown, Tintinalli, Rosen, Harriet Lane) plus web-checked guidelines; Ghai, Nelson and Dhingra were not available for verification.') box(s,0.7,1.2,0.12,2.6,'',TEAL,shape=MSO_SHAPE.RECTANGLE) text(s,1.0,1.1,7.4,2.2,'Epiglottitis and Acute Laryngotracheobronchitis (Croup)',40,WHITE,True,name='Title',anchor=MSO_ANCHOR.TOP) text(s,1.0,3.35,7.2,0.9,'Acute upper airway obstruction in children: anatomy, pathology, recognition and management',18,'BFD4EA') text(s,1.0,4.6,7.2,1.6,'Presenter: [Name, designation]\nDepartment: [Department of Paediatrics / ENT]\nInstitution: [Institution name]\nFinal-year MBBS seminar | [Date]',15,WHITE) box(s,8.6,0.5,4.3,6.5,'',WHITE,shape=MSO_SHAPE.ROUNDED_RECTANGLE,name='Panel') pic(s,A+'sag_normal.png',8.7,0.6,4.1,6.3,name='AirwayFigure') # ---------------- S2 objectives s=new('Learning objectives','A','Structure follows the requested syllabus. Sources are tagged on each slide.','Objectives. Emphasise that both conditions are causes of acute upper airway obstruction but have opposite management philosophies at the bedside.') objs=[('1','Aetiology and epidemiology','Hib and non-Hib bacteria, parainfluenza and other viruses; age and seasonal patterns',TEAL), ('2','Pathogenesis and anatomical pathology','Supraglottic cellulitis versus subglottic mucosal oedema; why small changes matter in children',RED), ('3','Clinical recognition and differential diagnosis','Toxic child with drooling versus barking cough; severity scoring; mimics',BLUE), ('4','Investigations and evidence-based management','Airway-first approach in epiglottitis; steroids and epinephrine in croup',TEAL), ('5','Complications, prevention and prognosis','Hib immunisation, contact prophylaxis, disposition and outcomes',PURPLE)] for i,(n,h,d,c) in enumerate(objs): y=1.45+i*1.05 box(s,0.6,y,0.8,0.85,n,c,WHITE,28,True,align=PP_ALIGN.CENTER,shape=MSO_SHAPE.OVAL) box(s,1.6,y,11.2,0.9,h+'||\n'+d,LIGHT,DARK,15,False) # ---------------- S3 intro s=new('Introduction and definitions','A',TB+'Rosen (Ch. 162), Scott-Brown Vol 2 (croup), Tintinalli (Ch. 126).','Define each condition, then link them through acute upper airway obstruction. Highlight that croup is common and mostly mild whereas epiglottitis is rare but can kill within hours.') box(s,0.6,1.45,6.0,2.35,'Acute epiglottitis||\nInvasive bacterial infection causing inflammation and oedema of the epiglottis, aryepiglottic folds, arytenoids and surrounding supraglottic tissues (Rosen). Often called supraglottitis.', 'FBE9E7',DARK,15,anchor=MSO_ANCHOR.TOP,line=RED) box(s,6.8,1.45,6.0,2.35,'Acute laryngotracheobronchitis (viral croup)||\nViral syndrome of hoarse voice, barking cough and inspiratory or biphasic stridor from mucosal oedema of the larynx and trachea (Scott-Brown). Bronchi may be involved.','E8F1FB',DARK,15,anchor=MSO_ANCHOR.TOP,line=BLUE) text(s,0.6,4.0,12,0.4,'How they relate and why they matter',18,NAVY,True) bullets(s,['Both narrow the upper airway: inspiratory stridor and retractions are the common final pathway.', 'Site of narrowing differs: supraglottic (epiglottitis) versus subglottic (croup); this explains the voice, cough and swallowing differences.', 'Croup is the most common cause of stridor outside the neonatal period (Tintinalli); epiglottitis is now rare but remains a time-critical emergency.', 'Children are predisposed to respiratory failure: small compressible airway, low FRC, high oxygen consumption, short safe apnoea time (Rosen).'],0.6,4.45,12.2,2.5,15) # ---------------- S4 anatomy s=new('Upper airway anatomy','A','Schematic drawn for this seminar (not to scale). Anatomy per standard texts; subglottis narrowest in children: Scott-Brown Vol 2.','Walk top to bottom: pharynx, vallecula, epiglottis, aryepiglottic folds, glottis, subglottis within cricoid, trachea. Stress cricoid = narrowest point in young children.') pic(s,A+'sag_normal.png',0.5,1.3,6.2,5.7,name='AirwayFigure') text(s,7.0,1.3,5.9,0.4,'Regions of the larynx',18,NAVY,True) bullets(s,['Supraglottis||: epiglottis, vallecula (mucosal pocket between tongue base and epiglottis), aryepiglottic folds, arytenoids, false cords', 'Glottis||: true vocal cords; narrowest part of the adult airway', 'Subglottis||: below the cords to the lower border of the cricoid, the only complete cartilaginous ring', 'Trachea||: C-shaped rings with posterior membrane'],7.0,1.75,5.9,2.7,14,gap=4) box(s,7.0,4.55,5.9,2.4,'Paediatric differences||\nLarynx sits higher; epiglottis is relatively long and floppy.\nSubglottis (cricoid level) is the narrowest segment, about 6.5 mm in an 18-month-old (Scott-Brown).\nLoose submucosa in the supraglottis and subglottis allows rapid oedema.', 'FFF4DD',DARK,13.5,anchor=MSO_ANCHOR.TOP,line=AMBER) # ---------------- S5 comparison anatomy s=new('Anatomical comparison: normal, epiglottitis, croup','A','Schematic for teaching. Site of obstruction per Rosen (epiglottitis) and Scott-Brown (croup).','Compare three panels. Supraglottic swelling = muffled voice, drooling, no barking cough. Subglottic swelling = barking cough, hoarse voice, steeple sign.') pic(s,A+'three.png',0.4,1.25,8.3,5.7,name='AirwayFigure') box(s,8.9,1.35,4.0,1.75,'Epiglottitis (supraglottic)||\nMuffled voice, drooling, dysphagia, soft stridor; cough usually absent; toxic','FBE9E7',DARK,13,anchor=MSO_ANCHOR.TOP,line=RED) box(s,8.9,3.2,4.0,1.75,'Croup (subglottic)||\nHoarse voice, barking cough, harsh inspiratory stridor; swallowing preserved; non-toxic','E8F1FB',DARK,13,anchor=MSO_ANCHOR.TOP,line=BLUE) box(s,8.9,5.05,4.0,1.85,'Why the difference?||\nStructures above the cords handle swallowing and resonance. The cords and subglottis generate voice and cough. Disease at each level disturbs that level\'s function.','F2F5F9',DARK,13,anchor=MSO_ANCHOR.TOP,line=GREY) # ---------------- S6 epiglottitis epidemiology s=new('Epiglottitis: definition, terminology and epidemiology','B',TB+'Rosen Ch. 162. Age range in pre-vaccine era from NWT Health guideline (web). Incidence trend: Rosen.','Terminology: epiglottitis vs supraglottitis. Post vaccine shift to older patients. Hib can still cause disease in fully immunised children.') bullets(s,['Acute epiglottitis||: cellulitis of the epiglottis; supraglottitis is the broader term as aryepiglottic folds, arytenoids and adjacent tissues are inflamed (Rosen)', 'Pre-vaccine era||: classically children about 2 to 7 years; onset to respiratory distress in under 12 hours', 'After Hib vaccination (introduced 1980s)||: incidence has declined markedly; epiglottitis is now relatively more common in older children and adults (Rosen)', 'Vaccinated patients||: Hib remains the most common infectious cause in children and can occur in fully immunised children (Rosen)', 'Adults||: present less dramatically because the airway is wider; sore throat out of proportion to findings and anterior neck tenderness (Rosen)'],0.6,1.4,8.2,5.4,15,gap=7) box(s,9.1,1.5,3.8,1.6,'Peak risk, pre-vaccine||\n2 to 7 years\nunvaccinated or incompletely vaccinated','FBE9E7',DARK,14,anchor=MSO_ANCHOR.TOP,line=RED) box(s,9.1,3.3,3.8,1.6,'Current pattern||\nRare in children\nOlder children and adults a larger share','F2F5F9',DARK,14,anchor=MSO_ANCHOR.TOP,line=GREY) box(s,9.1,5.1,3.8,1.7,'Teaching point||\nNot having seen a case does not make it impossible; keep the diagnosis in mind for any toxic child with drooling.','FFF4DD',DARK,13,anchor=MSO_ANCHOR.TOP,line=AMBER) # ---------------- S7 aetiology s=new('Epiglottitis: aetiology and microbiology','B',TB+'Rosen Ch. 162 (organisms, noninfectious causes). Less common causes are reported rather than quantified.','Hib classic. Others: non-b H influenzae, streptococci, S aureus incl MRSA, meningococcus. Immunocompromised: Pseudomonas, Candida. Non infectious mimics matter: thermal, caustic, allergic.') rows=[['Cause','Context','Teaching note'], ['Haemophilus influenzae type b','Classic; still the most common infectious cause in children','Unvaccinated or incompletely vaccinated; can occur despite full immunisation'], ['Other H. influenzae (types A, F, non-typeable)','Reported','Not prevented by the Hib conjugate vaccine'], ['Streptococci (S. pneumoniae, beta-haemolytic)','Reported, more in older patients','Non-Hib bacteria tend to have slower onset and less airway compromise'], ['Staphylococcus aureus including MRSA','Reported','Consider local MRSA prevalence when choosing empirical cover'], ['Neisseria meningitidis','Uncommon','Systemic features; invasive disease'], ['Pseudomonas aeruginosa, Candida','Immunocompromised','Necrotising epiglottitis described in immunodeficiency'], ['Noninfectious: hot liquids or steam, caustic ingestion, allergic reaction, foreign body, irritant injury, lymphoproliferative disease','Rare','Mimics: no fever or toxicity may be present; steroids not recommended for thermal airway burns (Rosen)']] table(s,rows,0.6,1.4,12.2,[3.4,3.0,5.0],12,RED,maxh=5.0) box(s,0.6,6.2,12.2,0.7,'Host factors and vaccination: immunocompromise, incomplete Hib immunisation and vaccine failure are the main host factors; the Hib conjugate vaccine does not protect against other organisms.','F2F5F9',DARK,12.5,line=GREY) # ---------------- S8 pathogenesis s=new('Epiglottitis: pathogenesis','B',TB+'Rosen Ch. 162 (protrusion over glottis, ball-valve). Submucosal anatomy: standard teaching.','Walk the flowchart left to right, top row then bottom row. Stress ball-valve effect and the risk of sudden complete obstruction.') steps=[('1 Entry','Respiratory droplets; nasopharyngeal colonisation by Hib or other bacteria'), ('2 Local invasion','Bacteria invade supraglottic mucosa; bacteraemia may accompany'), ('3 Inflammation','Neutrophilic cellulitis with vascular leak and cytokine release'), ('4 Oedema','Loose submucosa of epiglottis, aryepiglottic folds and arytenoids swells'), ('5 Inlet narrowing','Swollen structures protrude downward over the glottic opening; ball-valve effect on inspiration (Rosen)'), ('6 Obstruction','Turbulent flow and stridor; hypoxaemia; sudden complete obstruction possible')] cols=[TEAL,TEAL,AMBER,AMBER,RED,RED] for i,(h,d) in enumerate(steps): r=i//3; c=i%3; x=0.6+c*4.2; y=1.5+r*2.55 box(s,x,y,3.6,0.55,h,cols[i],WHITE,16,True,shape=MSO_SHAPE.RECTANGLE) box(s,x,y+0.55,3.6,1.5,d,LIGHT,DARK,14,shape=MSO_SHAPE.RECTANGLE,anchor=MSO_ANCHOR.TOP) if c<2: arrow(s,x+3.65,y+0.7,0.5,0.4,'right') arrow(s,12.1,3.4,0.5,0.6,'down'); box(s,0.6,6.55,12.2,0.45,'Agitation, crying and examination increase flow demand and secretions and can precipitate complete obstruction.','FFF4DD',DARK,13,bold=True,line=AMBER) # ---------------- S9 pathology s=new('Epiglottitis: pathology and anatomical changes','B','Schematic drawn for this seminar. Clinical images from the Orris medical image library (original publication not identified). Thumb sign and normal-film caveat: Rosen Ch. 162.','Correlate: swollen epiglottis and AE folds -> inlet narrowing; loss of vallecula air on X ray; cherry red oedematous epiglottis on laryngoscopy performed only in controlled setting.') pic(s,A+'sag_epi.png',0.4,1.3,4.9,5.6,name='AirwayFigure') bullets(s,['Macroscopic||: bright red (cherry red), markedly swollen, rounded epiglottis', 'Oedema||: aryepiglottic folds and arytenoids thickened, narrowing the laryngeal inlet', 'Airway effect||: swollen mass drapes over the glottis; ball-valve obstruction', 'Correlation||: dysphagia and drooling from pharyngeal pain and oedema; muffled voice from supraglottic swelling; cough absent because the subglottis is spared', 'Abscess or necrosis||: epiglottic abscess (adolescents), necrotising change (immunodeficiency)'],5.4,1.4,4.4,5.5,13,gap=5) pic(s,A+'epi_laryngo.jpg',9.9,1.3,3.1,2.6,caption='Laryngoscopy: oedematous, erythematous supraglottis',capsize=9) pic(s,A+'epi_xray.jpg',9.9,4.35,3.1,2.4,caption='Lateral neck film: thumb sign',capsize=9) # ---------------- S10 history s=new('Epiglottitis: clinical features, history','B',TB+'Rosen Ch. 162, Tintinalli Ch. 126, NWT Health guideline (web).','Take history only while keeping the child calm, on parent lap. Cough absence and drooling are the key discriminators from croup.') items=[('Onset','Rapid: hours, often under 12 h'),('Fever','High; sudden'),('Sore throat','Severe; odynophagia'),('Swallowing','Dysphagia, refuses fluids'),('Secretions','Drooling; cannot handle saliva'),('Voice and cough','Muffled voice; cough usually absent'),('Breathing','Noisy breathing, distress as it progresses'),('Preceding illness','Often none or minimal URI (contrast with croup)')] for i,(a,b) in enumerate(items): c=i%2; r=i//2; x=0.6+c*6.2; y=1.45+r*1.1 box(s,x,y,1.9,0.95,a,RED,WHITE,15,True,shape=MSO_SHAPE.RECTANGLE,align=PP_ALIGN.CENTER) box(s,x+1.9,y,4.1,0.95,b,'FBE9E7',DARK,14,shape=MSO_SHAPE.RECTANGLE) box(s,0.6,5.95,12.2,0.95,'Older children and adults: sore throat out of proportion to examination, voice change and anterior neck tenderness may be the only clues; stridor appears late (Rosen).','FFF4DD',DARK,14,line=AMBER) # ---------------- S11 exam s=new('Epiglottitis: clinical features, examination','B',TB+'Rosen Ch. 162, Tintinalli Ch. 126.','Observe from a distance. Do not open the mouth. Concerning: tripod, inability to swallow, silent child, stridor with fatigue, cyanosis, altered consciousness.') bullets(s,['Toxic, anxious appearance||: high fever, flushed, sits very still', 'Posture||: sniffing or tripod position, neck extended, chin and jaw forward to maximise airway patency (Rosen, Tintinalli)', 'Drooling||: prominent because swallowing is painful or impossible', 'Voice||: muffled ("hot potato"); cough and phonation often absent as symptoms worsen (Rosen)', 'Breathing||: tachypnoea, soft inspiratory stridor, retractions; effort may look deceptively quiet', 'Children versus adults||: young children appear dramatically ill; adults have larger airways, subtler signs and need greater swelling before symptoms'],0.6,1.4,7.6,5.5,15,gap=7) box(s,8.5,1.5,4.4,5.3,'Particularly concerning findings||\n\nInability to lie flat or leave tripod posture\nDrooling with refusal to swallow\nProgressive stridor, fatigue, falling effort\nAgitation changing to drowsiness\nCyanosis, bradycardia, low SpO2\n\nWhy: these indicate critical narrowing and exhaustion. Hypoxaemia and bradycardia are pre-arrest signs.','FBE9E7',DARK,14,anchor=MSO_ANCHOR.TOP,line=RED) # ---------------- S12 course s=new('Epiglottitis: clinical course and complications','B',TB+'Rosen Ch. 162 (abscess, necrotising epiglottitis, delayed diagnosis, intubation 3 to 5 days). Systemic spread: standard teaching.','Not every patient follows the same course; non-Hib bacteria and adults often progress more slowly.') text(s,0.6,1.35,6,0.4,'Course',18,RED,True) bullets(s,['Classically abrupt and fast in young children: hours from fever to obstruction', 'Slower in non-Hib causes and in adults (Rosen)', 'Delay in diagnosis is associated with increased mortality (Rosen)', 'With airway secured, patients often remain intubated 3 to 5 days while antibiotics reduce oedema (Rosen)'],0.6,1.8,6.0,3.4,14.5,gap=6) text(s,6.9,1.35,6,0.4,'Complications',18,RED,True) bullets(s,['Complete airway obstruction, hypoxaemia, respiratory arrest, hypoxic brain injury', 'Epiglottic abscess, particularly in adolescents (Rosen)', 'Necrotising epiglottitis in immunodeficiency (Rosen)', 'Bacteraemia and sepsis; spread to lung, pericardium, meninges or joints described with Hib (standard teaching)', 'Post-obstructive pulmonary oedema after relief of obstruction (standard teaching)'],6.9,1.8,6.0,3.6,14.5,gap=6) box(s,0.6,5.5,12.2,1.3,'Factors associated with severe disease||\nYounger age with small airway, Hib aetiology, delayed recognition, agitation or distressing examination, immunocompromise, thermal or caustic injury (rapid oedema).','F2F5F9',DARK,14,line=GREY,anchor=MSO_ANCHOR.TOP) # ---------------- S13 diagnosis & DDx s=new('Epiglottitis: diagnosis and differential diagnosis','B',TB+'Tintinalli Table 126-2 and Ch. 126, Rosen Ch. 162. Table condensed; features are typical, not absolute.','Diagnosis is clinical. Imaging only if stable and diagnosis uncertain and never at the expense of the airway.') rows=[['','Epiglottitis','Croup','Bacterial tracheitis','Retropharyngeal abscess','Foreign body'], ['Onset','Hours','1 to 3 days','URI then rapid toxicity','Days','Sudden, choking'], ['Fever / look','High, toxic','Low-grade, non-toxic','High, toxic','Fever, irritable','Afebrile'], ['Cough / voice','No cough, muffled','Barking cough, hoarse','Croupy cough','Neck stiffness, muffled','Cough, variable'], ['Drooling','Marked','Absent','Absent','Often','Variable'], ['Key point','Tripod, thumb sign','Steeple sign','Poor response to croup treatment','Prevertebral swelling on lateral film','Radiograph may be normal']] table(s,rows,0.6,1.35,12.2,[1.4,2.0,2.0,2.2,2.4,2.2],11.5,RED,maxh=3.3) bullets(s,['Airway assessment first||; senior anaesthesia and ENT early', 'Laboratory tests||: blood cultures and FBC support diagnosis but must wait until the airway is safe', 'Lateral neck radiograph||: thumb sign, thick aryepiglottic folds, absent vallecular air, dilated hypopharynx; but a substantial proportion of films are normal (Rosen quotes up to 70%) and moving the child is risky', 'Gold standard||: direct visualisation by an experienced operator during controlled airway management'],0.6,4.75,12.2,2.3,13.5,gap=4) # ---------------- S14 airway precautions s=new('Airway precautions: suspected epiglottitis is an airway emergency','B','Rosen Ch. 162 (stable patient not moved or repositioned for tests; controlled setting); Tintinalli Ch. 126.','Make this slide the emotional centre of the epiglottitis section. DO versus DO NOT.') box(s,0.6,1.35,12.2,0.85,'A child who is maintaining an airway must not be provoked into obstructing it. Plan airway management with experienced clinicians in a controlled, fully equipped setting.',RED,WHITE,17,True,align=PP_ALIGN.CENTER) box(s,0.6,2.45,5.9,0.5,'DO',TEAL,WHITE,18,True,align=PP_ALIGN.CENTER,shape=MSO_SHAPE.RECTANGLE) box(s,0.6,2.95,5.9,3.95,'Keep the child calm, on the parent\'s lap\nLet them stay in the position of comfort\nCall senior anaesthetist, ENT and paediatrician now\nGive oxygen only if tolerated (blow-by, held by parent)\nPrepare airway equipment: small tubes, laryngoscopes, rigid bronchoscope, surgical airway kit\nTransfer with an airway-skilled clinician (operating theatre is the usual venue)','E3F4F4',DARK,14.5,shape=MSO_SHAPE.RECTANGLE,anchor=MSO_ANCHOR.TOP) box(s,6.9,2.45,5.9,0.5,'DO NOT',RED,WHITE,18,True,align=PP_ALIGN.CENTER,shape=MSO_SHAPE.RECTANGLE) box(s,6.9,2.95,5.9,3.95,'Do not use a tongue depressor or examine the throat\nDo not force the child supine\nDo not take blood, cannulate or send to radiology if it distresses the child or delays the airway\nDo not separate child from parent\nDo not give sedatives without airway control\nDo not delay airway management for imaging or laboratory tests','FBE9E7',DARK,14.5,shape=MSO_SHAPE.RECTANGLE,anchor=MSO_ANCHOR.TOP) # ---------------- S15 emergency management s=new('Emergency management of epiglottitis: stepwise flowchart','B',TB+'Rosen Ch. 162 (airway before diagnostics; fiberoptic or surgical airway; second or third-generation cephalosporin).','Read each step with rationale. Airway stabilisation has priority over every diagnostic procedure.') st=[('1 Recognise','Fever, drooling, toxic, tripod, muffled voice','Early recognition prevents distressing manoeuvres'), ('2 Call for help','Senior anaesthesia, ENT, paediatrics','Difficult airway: needs best operator and surgical backup'), ('3 Keep calm','Parent lap, position of comfort','Agitation raises demand and can tip into obstruction'), ('4 Monitor and oxygen','SpO2, ECG; blow-by oxygen if tolerated','Detect deterioration without touching the child'), ('5 Secure airway','Controlled setting, usually theatre; inhalational induction by expert; ENT ready for rescue','Planned intubation or surgical airway is safest (Rosen)'), ('6 IV antibiotics','Start after airway control or when not distressing','Treat bacteraemia and shorten oedema'), ('7 ICU care','Sedation, ventilation, antibiotics; extubate when oedema settles','Often intubated 3 to 5 days (Rosen)')] for i,(a,b,c) in enumerate(st): y=1.3+i*0.78 box(s,0.6,y,3.0,0.62,a,RED if i==4 else NAVY,WHITE,14,True,shape=MSO_SHAPE.RECTANGLE) box(s,3.7,y,4.9,0.62,b,LIGHT,DARK,12.5,shape=MSO_SHAPE.RECTANGLE) box(s,8.7,y,4.2,0.62,c,'FFF4DD',DARK,12,shape=MSO_SHAPE.RECTANGLE) if i<6: arrow(s,1.9,y+0.62,0.3,0.16,'down',RED) text(s,3.7,6.77,4.9,0.3,'WHAT TO DO',10,GREY,True,check=False); text(s,8.7,6.77,4.2,0.3,'RATIONALE',10,GREY,True,check=False) # ---------------- S16 antibiotics s=new('Epiglottitis: antibiotics and supportive treatment','B','Antibiotic classes: Rosen Ch. 162 and overviews (ScienceDirect, Medscape); doses: NWT Health guideline and Sawyer 1994 RCT (PMID 8129435). Duration not verified: use local guideline.','Emphasise that doses must be checked against local formulary. Mention allergy alternatives from reviews.') rows=[['Principle','Detail (source)'], ['Empirical IV therapy','Second or third-generation cephalosporin recommended (Rosen). Reasonable options: ceftriaxone, cefotaxime, ampicillin-sulbactam (reviews)'], ['Coverage','Hib (including beta-lactamase producers), streptococci, S. aureus; add MRSA cover if locally prevalent'], ['Example doses','Ceftriaxone 100 mg/kg IV then 50 mg/kg after 24 h (RCT protocol, Sawyer 1994); cefuroxime 150 mg/kg/day IV in 3 doses (NWT guideline). Verify with local formulary'], ['Beta-lactam allergy','Carbapenem or fluoroquinolone alternatives suggested in reviews; discuss with microbiology'], ['Tailor','Blood and epiglottic cultures when safe; narrow to sensitivities'], ['Duration, oral switch','Not verified in a single authoritative source here; follow local guideline after clinical improvement'], ['Supportive','IV fluids, antipyretics, humidified oxygen after intubation, ICU monitoring, extubation when oedema reduced (leak, direct view)']] table(s,rows,0.6,1.4,12.2,[2.4,9.8],12.5,RED,maxh=5.4) # ---------------- S17 prevention s=new('Epiglottitis: prevention, prognosis and follow-up','B','Rifampin regimen: ScienceDirect overview and Medscape (web); delay and mortality: Rosen. India schedule: standard teaching, verify against current UIP/IAP schedule.','Contact prophylaxis depends on confirmed invasive Hib and household composition. Mention pentavalent vaccine.') box(s,0.6,1.4,4.0,2.6,'Prevention||\nHib conjugate vaccine (in India given within the pentavalent vaccine; check the current schedule). Complete primary series and booster. Vaccine does not cover non-b or non-H. influenzae causes.','E3F4F4',DARK,13,anchor=MSO_ANCHOR.TOP,line=TEAL) box(s,4.8,1.4,4.0,2.6,'Contact prophylaxis||\nRifampin 20 mg/kg once daily (max 600 mg) for 4 days when Hib is isolated and the household has an infant under 12 months, under-vaccinated child under 4 years, or immunocompromised child; includes the index case.','FFF4DD',DARK,12.5,anchor=MSO_ANCHOR.TOP,line=AMBER) box(s,9.0,1.4,3.9,2.6,'Prognosis||\nExcellent with timely airway control and antibiotics. Mortality is increased with delayed diagnosis (Rosen). Full recovery expected.','F2F5F9',DARK,13,anchor=MSO_ANCHOR.TOP,line=GREY) text(s,0.6,4.2,12,0.4,'Public health and follow-up',18,NAVY,True) bullets(s,['Notify invasive Hib disease per local public-health rules; droplet precautions for 24 hours of effective therapy (standard practice)', 'Check immunisation status of the child and complete the schedule', 'Recurrent epiglottitis, especially in adults, warrants immune evaluation (Medscape)', 'Prophylaxis indications depend on the organism isolated: not needed for non-Hib causes'],0.6,4.65,12.2,2.4,14.5,gap=5) # ---------------- S18 croup definition s=new('Croup: definition and terminology','C',TB+'Scott-Brown Vol 2 (Croup), Tintinalli Ch. 126, Rosen Ch. 162.','Define croup clinically. Terms: laryngotracheitis, LTB, viral croup. Spasmodic croup is a related recurrent form; not addressed in sources I verified.') box(s,0.6,1.4,12.2,1.5,'Viral croup (acute laryngotracheobronchitis)||\nA clinical syndrome of hoarseness, a distinctive barking cough and inspiratory or biphasic stridor, usually after upper respiratory symptoms, due to mucosal oedema of the larynx and trachea after a viral illness (Scott-Brown).','E8F1FB',DARK,15.5,anchor=MSO_ANCHOR.TOP,line=BLUE) bullets(s,['Terminology||: croup, laryngotracheitis, laryngotracheobronchitis (LTB) are used interchangeably; the bronchi are involved in some children', 'Typical features||: 6 months to 3 years, URI prodrome, barking cough, hoarseness, stridor worse at night; no drooling and not toxic (Scott-Brown)', 'Not typical croup||: drooling, toxic look, high fever, abrupt onset, no URI, age outside 6 months to 6 years, poor response to steroids', 'Alternative causes of stridor||: epiglottitis, bacterial tracheitis, foreign body, retropharyngeal abscess, laryngomalacia, subglottic stenosis (consider with recurrent croup, Scott-Brown), angioedema, burns'],0.6,3.15,12.2,3.8,15,gap=8) # ---------------- S19 epi & aetiology croup s=new('Croup: epidemiology and aetiology','C',TB+'Tintinalli Ch. 126, Scott-Brown Vol 2. Relative frequencies not quantified in these sources.','Peak 2 years, boys more, autumn, biennial PIV1. Coinfection can occur.') rows=[['Virus','Notes (source)'], ['Parainfluenza virus type 1','Classic cause; biennial autumn epidemics in odd years in USA and Canada (Scott-Brown)'], ['Parainfluenza virus type 2 and 3','Also cause croup (type 3 listed as parainfluenza in Tintinalli); more variable'], ['Rhinovirus','Among the most common viruses with parainfluenza (Tintinalli)'], ['Respiratory syncytial virus','Recognised cause (Scott-Brown)'], ['Influenza, metapneumovirus, enterovirus, coronavirus, bocavirus','Reported; detection methods increase list (Tintinalli, Scott-Brown)'], ['Measles','Important where measles remains prevalent (Tintinalli)']] table(s,rows,0.6,1.4,7.9,[3.0,4.9],12,BLUE,maxh=4.4) box(s,8.8,1.4,4.1,5.4,'Epidemiology||\nAge: 6 months to 3 years; peak 2 years\nBoys > girls\nIncidence 1.5% to 6% per year in under 6s (Scott-Brown)\nSeason: autumn and early winter, sporadic all year\nTransmission: droplets, contact; coinfection is not uncommon; bacterial superinfection rare (Tintinalli)\nRisk of severe course: pre-existing subglottic narrowing, chronic lung disease, airway reactivity (Scott-Brown)','E8F1FB',DARK,13.5,anchor=MSO_ANCHOR.TOP,line=BLUE) text(s,0.6,5.9,7.9,0.9,'The pre-existing narrowing, such as subglottic stenosis, should be suspected in children with recurrent croup; endoscopy is advised in persistent cases (Scott-Brown).',12.5,GREY,italic=True) # ---------------- S20 pathogenesis croup s=new('Croup: paediatric airway anatomy and pathogenesis','C',TB+'Scott-Brown Vol 2 (1 mm oedema in 6.5 mm subglottis reduces area by about 50%). Schematic drawn for this seminar.','Subglottis narrowest, cricoid is rigid ring so oedema must encroach inwards.') pic(s,A+'cross.png',0.4,1.3,7.2,3.9) pic(s,A+'sag_croup.png',7.8,1.25,5.2,4.4,name='AirwayFigure') bullets(s,['Virus infects laryngeal and tracheal epithelium; mucosal inflammation and oedema in the subglottis (narrowest, enclosed by cricoid)', 'Narrowed lumen: higher resistance, turbulent airflow; vocal cord swelling gives hoarseness; barking cough and inspiratory stridor'],0.6,5.4,7.2,1.6,13.5,gap=4) box(s,7.9,5.75,5.0,1.2,'Result||\nSubglottic narrowing: "steeple" on AP radiograph','E8F1FB',DARK,13,line=BLUE) # ---------------- S21 pathology croup s=new('Croup: pathology and clinical correlation','C','Flow-resistance chart computed for this seminar (Poiseuille, laminar model). Scott-Brown Vol 2 for the 6.5 mm example.','Radius to the 4th power. Turbulent flow makes it worse. Why infants decompensate.') pic(s,A+'resist.png',7.3,1.35,5.6,3.7) bullets(s,['Inflammation of larynx and trachea; bronchi may be involved', 'Subglottic mucosa and submucosa oedematous; epithelium sloughs; hyperaemic and infiltrated by inflammatory cells (standard teaching)', 'Worked example (Scott-Brown): 1 mm of oedema in an 18-month-old with a 6.5 mm subglottis cuts cross-sectional area by about 50%', 'Laminar resistance rises as 1/r^4; turbulence worsens the effect', 'Infants have less reserve, fatigue sooner, and crying increases flow and turbulence'],0.6,1.4,6.5,5.5,14.5,gap=7) box(s,7.3,5.25,5.6,1.6,'Correlation||\nHoarse voice: cords swollen. Barking cough: subglottic oedema. Inspiratory stridor: turbulent flow in extrathoracic airway. Worse when crying or at night.','F2F5F9',DARK,12.5,anchor=MSO_ANCHOR.TOP,line=GREY) # ---------------- S22 croup clinical s=new('Croup: clinical features','C',TB+'Tintinalli Ch. 126 (prodrome, course), Scott-Brown Vol 2 (course, mortality).','Typical course 3 to 4 days. Atypical features should prompt reconsideration.') bullets(s,['Prodrome||: 1 to 3 days of coryza, cough and low-grade fever (Tintinalli)', 'Barking, seal-like cough||, hoarse voice', 'Inspiratory stridor||, initially on crying then at rest; biphasic in more severe disease', 'Fever||: usually low grade; child non-toxic, swallows saliva', 'Distress||: tachypnoea, suprasternal and intercostal retractions, nasal flaring', 'Night worsening||: symptoms often worse at night (Tintinalli)'],0.6,1.4,7.4,5.5,15,gap=7) box(s,8.3,1.5,4.6,2.45,'Typical course||\nSelf-limited; most resolve within 3 days (Tintinalli); 50% improve within 24 h and most recover within 4 days without treatment (Scott-Brown). Mortality about 1 in 30 000.','E8F1FB',DARK,13,anchor=MSO_ANCHOR.TOP,line=BLUE) box(s,8.3,4.15,4.6,2.7,'Atypical features: reconsider diagnosis||\nDrooling, toxic appearance, high fever, abrupt onset, recurrent episodes, poor response to steroids, stridor lasting beyond a week, age under 6 months.','FFF4DD',DARK,13,anchor=MSO_ANCHOR.TOP,line=AMBER) # ---------------- S23 severity s=new('Croup: clinical severity assessment','C','Severity categories synthesised from Westley components, Tintinalli, NHS Highland guideline (web), and standard teaching. Use local scoring conventions.','Cyanosis and drowsiness are late. Do not wait.') rows=[['Feature','Mild','Moderate','Severe / impending failure'], ['Stridor','Only when agitated or crying','At rest, audible','At rest, may diminish if exhausted'], ['Retractions','None or mild','Moderate','Severe, tiring'], ['Air entry','Normal','Normal or mildly decreased','Markedly decreased'], ['Mental state','Alert, playful','Anxious, agitated','Lethargic, drowsy, altered (late)'], ['Cyanosis / SpO2','None, normal','None','Cyanosis, hypoxaemia (late)'], ['Typical action','Dexamethasone, home if stridor-free','Dexamethasone plus nebulised epinephrine','Epinephrine, steroid, senior help, ICU']] table(s,rows,0.6,1.4,12.2,[2.0,3.0,3.3,3.9],12.5,BLUE,hfills=[NAVY,'2E8B57',AMBER,RED],maxh=4.4) box(s,0.6,5.65,12.2,1.2,'Late and concerning||\nCyanosis, altered consciousness, silent chest and fatigue indicate impending respiratory failure. Stridor may paradoxically quieten as the child tires. Treat immediately and call senior help.', 'FBE9E7',DARK,14,anchor=MSO_ANCHOR.TOP,line=RED) # ---------------- S24 Westley s=new('Westley croup score','C',TB+'Scott-Brown Vol 2 Table 29.1 (from Westley 1978) and Tintinalli Table 126-3 (modified). Cut-offs differ between sources: see right.','Component scores identical across sources. Max 17. Do not delay treatment while scoring.') rows=[['Component','0','1','2','3','4','5'], ['Level of consciousness','Normal','','','','','Altered'], ['Cyanosis','None','','','','With agitation','At rest'], ['Stridor','None','With agitation / by stethoscope','At rest / without stethoscope','','',''], ['Air entry','Normal','Decreased','Severely decreased','','',''], ['Chest wall retractions','None','Mild','Moderate','Severe','','']] table(s,rows,0.5,1.4,8.6,[2.2,0.9,1.5,1.5,0.9,1.1,0.9],11,BLUE,maxh=3.6) text(s,0.5,4.55,8.6,0.4,'Total 0 to 17. Stridor wording: Westley original uses "audible with stethoscope"; modified versions use "with agitation".',11,GREY,italic=True) rows=[['Source','Mild','Moderate','Severe'], ['Scott-Brown (Westley)','2 to 3','4 to 7','8 or more'], ['Tintinalli (modified)','under 4','4 to 6','over 6'], ['AMBOSS summary (web)','2 or less','3 to 7','8 to 11; 12 or more impending failure']] table(s,rows,9.3,1.4,3.7,[1.6,0.7,0.8,1.2],10,NAVY,maxh=3.3) box(s,0.5,5.1,12.5,1.8,'Use and limits||\nValidated research tool; score correlates with tracheal lumen (Scott-Brown). Inter-observer variability; less used in daily practice. Cut-offs vary: adopt the one in your local guideline. Never delay dexamethasone, epinephrine or airway help while calculating a score.','E8F1FB',DARK,13.5,anchor=MSO_ANCHOR.TOP,line=BLUE) # ---------------- S25 diagnosis croup s=new('Croup: diagnosis and investigations','C',TB+'Scott-Brown Vol 2 (radiograph, Fig 29.1), Tintinalli Ch. 126. Second image from Orris library (original publication not identified).','Clinical diagnosis. Avoid radiology in distressed child.') bullets(s,['Diagnosis is clinical||; laboratory and viral tests are unnecessary in typical croup', 'Radiograph (AP neck)||: steeple or pencil-tip sign only if diagnostic dilemma in severe cases (Scott-Brown); can be normal and does not predict severity', 'Further assessment||: atypical features, poor response to treatment, toxic child, suspected foreign body, epiglottitis or tracheitis (Tintinalli)', 'Endoscopy||: persistent or recurrent croup to look for subglottic stenosis or other lesions', 'Safety||: do not send a distressed child to radiology unaccompanied; no throat examination; keep with parent'],0.6,1.4,6.6,5.5,14.5,gap=7) pic(s,A+'steeple_sb.png',7.5,1.35,2.7,3.3,caption='Steeple sign (Scott-Brown Fig 29.1)',capsize=9) pic(s,A+'steeple_pmc.jpg',10.3,1.35,2.7,3.3,caption='Steeple sign, AP neck',capsize=9) box(s,7.5,5.0,5.4,1.85,'Limited role of tests||\nNo test is needed in typical uncomplicated croup. Testing should never delay steroid or epinephrine treatment, and must never involve distressing the child.','FFF4DD',DARK,13,anchor=MSO_ANCHOR.TOP,line=AMBER) # ---------------- S26 DDx croup s=new('Differential diagnosis of croup','C',TB+'Tintinalli Table 126-2, Rosen Ch. 162 (tracheitis, foreign body). RPA features: standard teaching.','Compare. Key triggers for alternative diagnosis.') rows=[['','Croup','Epiglottitis','Bacterial tracheitis','Foreign body','Retropharyngeal abscess'], ['Onset','1 to 3 days after URI','Hours','URI then acute worsening','Sudden, choking','Days; sore throat'], ['Fever','Low grade','High','High','None','Present'], ['Cough','Barking','Absent','Croupy, productive','Cough/wheeze','Variable'], ['Voice','Hoarse','Muffled','Hoarse','Variable','Muffled'], ['Drooling','No','Yes','No','Variable','Often, neck stiff'], ['Appearance','Non-toxic','Toxic','Toxic','Distressed, well','Toxic, torticollis'], ['Airway finding','Subglottic narrowing','Swollen epiglottis','Irregular tracheal wall, purulent secretions','Radiopaque or air-trapping (may be normal)','Widened prevertebral space'], ['Distinguisher','Responds to steroid, epinephrine','Airway emergency','Fails croup treatment; bronchoscopy','Bronchoscopy','CT; drainage']] table(s,rows,0.6,1.35,12.2,[1.4,2.1,2.0,2.4,2.2,2.1],10.5,BLUE,maxh=5.6) # ---------------- S27 treatment s=new('Croup: evidence-based treatment','C',TB+'Scott-Brown Vol 2, Rosen Ch. 162, Tintinalli; NHS Highland guideline (web); Cochrane 2011 glucocorticoids. Doses on next slide.','Steroid for everyone. Epinephrine for moderate/severe. Observe after epinephrine. Avoid sedation, mist, antibiotics.') cards=[('Calm','Keep with parent, minimal disturbance; no throat exam; sedation not advised (Scott-Brown)',NAVY), ('Corticosteroid','Mainstay; single oral dexamethasone, all severities incl. mild (Cochrane: benefit by 6 h, to 12 h)',TEAL), ('Nebulised epinephrine','Moderate to severe, in addition to steroid; effect brief so observe (Rosen)',BLUE), ('Oxygen','For hypoxaemia or severe croup, delivered with parent assistance',PURPLE)] for i,(h,d,c) in enumerate(cards): x=0.6+i*3.1 box(s,x,1.4,2.95,0.55,h,c,WHITE,15,True,shape=MSO_SHAPE.RECTANGLE,align=PP_ALIGN.CENTER) box(s,x,1.95,2.95,1.9,d,LIGHT,DARK,12.5,shape=MSO_SHAPE.RECTANGLE,anchor=MSO_ANCHOR.TOP) text(s,0.6,4.0,6,0.4,'Precautions',17,NAVY,True) bullets(s,['Observe 2 to 4 h after nebulised epinephrine for symptom return (AMBOSS)', 'Intramuscular dexamethasone is not first line (Scott-Brown)','Dexamethasone effect begins within hours and lasts up to about 72 h'],0.6,4.4,6.2,2.5,13.5,gap=5) box(s,7.0,4.0,5.9,2.9,'Avoid / not routinely recommended||\nRoutine antibiotics for uncomplicated viral croup\nSedatives (respiratory depression, Scott-Brown)\nMist tents or humidification: no demonstrated clinical benefit (Scott-Brown)\nUnproven interventions as substitute for steroid','FBE9E7',DARK,13.5,anchor=MSO_ANCHOR.TOP,line=RED) # ---------------- S28 med table s=new('Croup: medication table','C','Doses: NHS Highland croup guideline (web, accessed 2026); Scott-Brown Vol 2; Harriet Lane 23e (dexamethasone); onset/observation: AMBOSS (secondary). Verify with local guideline.','Dose ranges differ. Newer meta-analysis (Front Pediatr 2026, PMID 42698708) compares 0.15 vs 0.6 mg/kg; I did not review its conclusions in detail. Epinephrine dose given from NHS Highland; racemic dosing not verified.') rows=[['Medication','Indication','Route','Dose / maximum','Onset / duration','Precautions'], ['Dexamethasone','All severities (recommended)','Oral; IV if needed','Single dose 0.15 mg/kg (NHS Highland); 0.6 mg/kg (Scott-Brown, Harriet Lane, usual max 16 mg); can repeat after 6 to 12 h per NHS Highland','Within about 6 h; benefit to about 12 h (Cochrane), up to 72 h (AMBOSS)','IM not first line (muscle necrosis); vomiting: use budesonide'], ['Budesonide (nebulised)','If too unwell or vomiting','Nebulised','2 mg single dose (NHS Highland, Scott-Brown)','Similar steroid effect','Alternative only'], ['Epinephrine (nebulised)','Moderate to severe croup','Nebulised','1:1000 at 400 micrograms/kg, max 5 mg; repeat after 30 min if needed (NHS Highland)','Within about 30 min; observe 2 to 4 h for return (AMBOSS)','Tachycardia, pallor; repeated need = admit; always give steroid'], ['Oxygen','Hypoxaemia, severe croup','Mask / blow-by, parent-assisted','Titrate to SpO2 (high flow in severe)','Immediate','Do not distress child'], ['Not routinely recommended','Antibiotics (viral), sedatives, mist/humidification','-','-','-','No benefit or harm (Scott-Brown)']] table(s,rows,0.5,1.35,12.4,[1.5,1.7,1.3,3.5,2.3,2.1],10,BLUE,maxh=5.6) # ---------------- S29 disposition s=new('Croup: disposition, admission and discharge','C','Rosen Ch. 162 (discharge after observation), NHS Highland guideline (1 to 2 h stridor review), AMBOSS (age under 6 months, observation 2 to 4 h). Local protocols apply.','Disposition depends on assessment and local guideline.') box(s,0.6,1.4,6.0,0.5,'Safe for discharge',TEAL,WHITE,16,True,shape=MSO_SHAPE.RECTANGLE,align=PP_ALIGN.CENTER) box(s,0.6,1.9,6.0,3.3,'No stridor at rest and no significant distress after observation (Rosen)\nPeriod of observation after epinephrine completed without recurrence\nNormal SpO2, drinking well\nReliable carers, can return quickly; access to follow-up\nSafety-net advice given','E3F4F4',DARK,14,shape=MSO_SHAPE.RECTANGLE,anchor=MSO_ANCHOR.TOP) box(s,6.8,1.4,6.0,0.5,'Admit',RED,WHITE,16,True,shape=MSO_SHAPE.RECTANGLE,align=PP_ALIGN.CENTER) box(s,6.8,1.9,6.0,3.3,'Persistent stridor at rest or work of breathing\nReturn of symptoms after epinephrine; repeated doses\nHypoxaemia, poor intake, dehydration\nAge under 6 months (AMBOSS); atypical or toxic presentation\nSocial or access concerns','FBE9E7',DARK,14,shape=MSO_SHAPE.RECTANGLE,anchor=MSO_ANCHOR.TOP) box(s,0.6,5.4,12.2,1.45,'Senior review / PICU / airway support||\nSevere croup, fatigue, falling air entry, cyanosis or altered consciousness, poor response to epinephrine and steroid: senior anaesthetist and ICU. Intubation needed in about 1 to 3% of those with impending failure (NHS Highland).','FFF4DD',DARK,13.5,anchor=MSO_ANCHOR.TOP,line=AMBER) # ---------------- S30 complications prognosis s=new('Croup: complications and prognosis','C',TB+'Scott-Brown Vol 2 (course, mortality, recurrent croup), NHS Highland (prognosis), Tintinalli (superinfection). Other complications: standard teaching.','Mostly benign.') text(s,0.6,1.35,6,0.4,'Complications',18,BLUE,True) bullets(s,['Respiratory deterioration and failure needing airway support in a small minority', 'Bacterial superinfection: tracheitis, pneumonia (Tintinalli)', 'Dehydration from poor intake', 'Rare: post-obstructive pulmonary oedema, hypoxic injury', 'Rare death: about 1 in 30 000 (Scott-Brown)'],0.6,1.8,6.0,3.8,14.5,gap=6) text(s,6.9,1.35,6,0.4,'Prognosis and course',18,BLUE,True) bullets(s,['Mild croup self-limiting; steroid shortens time to resolution (NHS Highland)', 'Most children recover within about 3 to 4 days', 'Severe croup: excellent prognosis with dexamethasone plus nebulised epinephrine (NHS Highland)', 'Cough may persist a few days'],6.9,1.8,6.0,3.2,14.5,gap=6) box(s,0.6,5.3,12.2,1.55,'Suspect an alternative or complicated disease if||\nToxic or high fever, no response to steroid and epinephrine, symptoms beyond a week, drooling, purulent secretions, recurrent episodes (subglottic stenosis, allergy, reflux).','FFF4DD',DARK,14,anchor=MSO_ANCHOR.TOP,line=AMBER) # ---------------- S31 comparison tables hd=['','Epiglottitis','Croup'] rowsA=[hd,['Definition','Supraglottic bacterial cellulitis','Viral laryngotracheobronchitis'], ['Aetiology','Hib; strep, S. aureus, others','Parainfluenza, RSV, rhinovirus'], ['Age / epidemiology','Rare now; any age; pre-vaccine 2 to 7 y','6 mo to 3 y; autumn'], ['Onset','Hours','1 to 3 days after URI'], ['Fever / appearance','High; toxic','Low; non-toxic'], ['Cough / voice','No cough; muffled','Barking; hoarse'], ['Drooling / dysphagia','Marked','Absent'], ['Stridor / effort','Soft, late; tripod','Harsh inspiratory; retractions'], ['Anatomical site','Supraglottis','Subglottis']] s=new('Epiglottitis versus croup: comprehensive comparison (1 of 2)','D','Synthesis of slides 6 to 30. Tintinalli Table 126-2; Rosen; Scott-Brown.','Colour: red epiglottitis, blue croup.') table(s,rowsA,0.6,1.4,12.2,[2.4,4.9,4.9],13,NAVY,hfills=[NAVY,RED,BLUE],maxh=5.5) rowsB=[hd,['Diagnostic approach','Clinical; airway visualisation in OR; X-ray optional','Clinical; X-ray rarely'], ['Initial management','Airway team; keep calm; no throat exam','Calm; assess severity; steroid'], ['Airway precautions','Controlled intubation; no distress','Avoid agitation; no throat exam'], ['Treatment','Secure airway; IV cephalosporin; ICU','Dexamethasone; nebulised epinephrine; oxygen'], ['Complications','Obstruction, sepsis, abscess','Respiratory failure rare; tracheitis'], ['Prevention','Hib vaccine; rifampin contacts','No specific; hygiene']] s=new('Epiglottitis versus croup: comprehensive comparison (2 of 2)','D','Synthesis. Tintinalli Table 126-2; Rosen; Scott-Brown; guidelines per slides 16 and 28.','Management differences.') table(s,rowsB,0.6,1.4,12.2,[2.4,4.9,4.9],13.5,NAVY,hfills=[NAVY,RED,BLUE],maxh=5.5) # ---------------- S32 integrated flow s=new('Integrated approach to a child with stridor','D','Algorithm synthesised for teaching from Rosen Ch. 162, Tintinalli Ch. 126, Scott-Brown; follow local protocol.','Airway safety is first. No throat exam.') box(s,3.2,1.3,6.9,0.8,'Child with stridor: airway, breathing, circulation, SpO2, work of breathing. Keep calm on parent lap.',NAVY,WHITE,14,True,align=PP_ALIGN.CENTER) box(s,0.6,2.3,12.2,0.55,'Impending failure (cyanosis, drowsy, exhausted)? Oxygen as tolerated, call senior airway team and ICU now.',RED,WHITE,13.5,True,align=PP_ALIGN.CENTER) arrow(s,6.4,2.1,0.5,0.2,'down') cols=[('Toxic, drooling, tripod, muffled, abrupt','Epiglottitis','Airway team; theatre; IV antibiotics',RED), ('Barking cough, hoarse, URI, non-toxic','Croup','Severity; dexamethasone; epinephrine if moderate to severe',BLUE), ('Sudden choking, no fever','Foreign body','Urgent bronchoscopy',AMBER), ('Toxic, purulent secretions, no croup response','Bacterial tracheitis','Bronchoscopy; IV antibiotics',PURPLE), ('Neck stiffness, torticollis, fever','Retropharyngeal abscess','CT; antibiotics; drainage',GREY)] for i,(a,b,c,col) in enumerate(cols): x=0.6+i*2.48 box(s,x,3.1,2.35,1.15,a,LIGHT,DARK,11.5,line=col) arrow(s,x+1.0,4.27,0.35,0.22,'down',col) box(s,x,4.5,2.35,0.5,b,col,WHITE,13,True,align=PP_ALIGN.CENTER) box(s,x,5.0,2.35,1.0,c,LIGHT,DARK,11.5,anchor=MSO_ANCHOR.TOP) box(s,0.6,6.2,12.2,0.75,'Reassess repeatedly; escalate if worsening. Disposition by response, local protocol and carer reliability. Never examine the throat or delay airway support.','FFF4DD',DARK,13,True,line=AMBER) # ---------------- S33 summary s=new('Summary and high-yield clinical pearls','D','Synthesis of

cd /tmp/workspace/epiglottitis-croup && cat > src/build.py <<'EOF' import math, copy from pptx import Presentation from pptx.util import Inches, Pt, Emu from pptx.dml.color import RGBColor from pptx.enum.text import PP_ALIGN, MSO_ANCHOR from pptx.enum.shapes import MSO_SHAPE, MSO_CONNECTOR from pptx.oxml.ns import qn from pptx.oxml import parse_xml from lxml import etree from PIL import Image A='assets/' NAVY='1F3A5F'; TEAL='0E7C86'; RED='B3261E'; BLUE='2A6FBB'; GREY='5F6B7A'; LRED='FBE9E7'; LBLUE='E3F0FB'; LGREY='F3F5F8'; AMB='F2A900'; GREEN='2E7D32'; LGREEN='E8F5E9'; LAMB='FFF4D6' def rgb(h): return RGBColor.from_string(h) prs=Presentation(); prs.slide_width=Inches(13.333); prs.slide_height=Inches(7.5) BL=prs.slide_layouts[6] WARN=[] CNT=[0] def est_h(text,w,pt,spacing=1.2): cpl=max(1,(w-0.15)/(0.0078*pt)); lines=sum(max(1,math.ceil(len(p)/cpl)) for p in text.split('\n')) return lines*pt*spacing/72+0.1 def add_morph(sl): ns='xmlns:mc="http://schemas.openxmlformats.org/markup-compatibility/2006" xmlns:p="http://schemas.openxmlformats.org/presentationml/2006/main" xmlns:p14="http://schemas.microsoft.com/office/powerpoint/2010/main" xmlns:p159="http://schemas.microsoft.com/office/powerpoint/2015/09/main"' x=f'<mc:AlternateContent {ns}><mc:Choice Requires="p159"><p:transition spd="slow" p14:dur="1200"><p159:morph option="byObject"/></p:transition></mc:Choice><mc:Fallback><p:transition spd="slow"><p:fade/></p:transition></mc:Fallback></mc:AlternateContent>' sl._element.append(etree.fromstring(x)) def tx(sl,text,x,y,w,h,size=14,bold=False,color='222222',align=PP_ALIGN.LEFT,anchor=MSO_ANCHOR.TOP,name=None,italic=False): tb=sl.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h)); tf=tb.text_frame; tf.word_wrap=True tf.margin_left=tf.margin_right=Inches(0.05); tf.margin_top=tf.margin_bottom=Inches(0.03); tf.vertical_anchor=anchor if name: tb.name=name for i,line in enumerate(text.split('\n')): p=tf.paragraphs[0] if i==0 else tf.add_paragraph(); p.alignment=align r=p.add_run(); r.text=line; f=r.font; f.size=Pt(size); f.bold=bold; f.italic=italic; f.name='Calibri'; f.color.rgb=rgb(color) if est_h(text,w,size)>h+0.15: WARN.append(f'slide {CNT[0]} textbox overflow? "{text[:30]}" est {est_h(text,w,size):.2f} > {h}') return tb def box(sl,text,x,y,w,h,fill=NAVY,fc='FFFFFF',size=13,bold=False,align=PP_ALIGN.CENTER,shape=MSO_SHAPE.ROUNDED_RECTANGLE,line=None,anchor=MSO_ANCHOR.MIDDLE,name=None): s=sl.shapes.add_shape(shape,Inches(x),Inches(y),Inches(w),Inches(h)) if name: s.name=name s.fill.solid(); s.fill.fore_color.rgb=rgb(fill) if line: s.line.color.rgb=rgb(line); s.line.width=Pt(1.5) else: s.line.fill.background() s.shadow.inherit=False if shape==MSO_SHAPE.ROUNDED_RECTANGLE: try: s.adjustments[0]=0.12 except: pass tf=s.text_frame; tf.word_wrap=True; tf.vertical_anchor=anchor tf.margin_left=tf.margin_right=Inches(0.08); tf.margin_top=tf.margin_bottom=Inches(0.04) for i,line_ in enumerate(text.split('\n')): p=tf.paragraphs[0] if i==0 else tf.add_paragraph(); p.alignment=align if '::' in line_: a,b=line_.split('::',1); r=p.add_run(); r.text=a; r.font.bold=True; r.font.size=Pt(size); r.font.color.rgb=rgb(fc); r.font.name='Calibri' r=p.add_run(); r.text=b; r.font.size=Pt(size); r.font.color.rgb=rgb(fc); r.font.name='Calibri' else: r=p.add_run(); r.text=line_; r.font.bold=bold; r.font.size=Pt(size); r.font.color.rgb=rgb(fc); r.font.name='Calibri' if est_h(text,w,size)>h+0.1: WARN.append(f'slide {CNT[0]} box overflow? "{text[:30]}" est {est_h(text,w,size):.2f} > {h}') return s def bullets(sl,items,x,y,w,h,size=14,color='222222',gap=4): tb=sl.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h)); tf=tb.text_frame; tf.word_wrap=True tf.margin_left=tf.margin_right=Inches(0.05); tf.margin_top=Inches(0.03) tot=0; first=True for it in items: t,lvl=(it,0) if isinstance(it,str) else it p=tf.paragraphs[0] if first else tf.add_paragraph(); first=False p.space_after=Pt(gap); sz=size-(1.5 if lvl else 0) if '::' in t: a,b=t.split('::',1); r=p.add_run(); r.text=a; r.font.bold=True; r.font.size=Pt(sz); r.font.color.rgb=rgb(NAVY); r.font.name='Calibri' r=p.add_run(); r.text=b; r.font.size=Pt(sz); r.font.color.rgb=rgb(color); r.font.name='Calibri' else: r=p.add_run(); r.text=t; r.font.size=Pt(sz); r.font.color.rgb=rgb(color); r.font.name='Calibri' pPr=p._p.get_or_add_pPr(); pPr.set('marL',str(int(Inches(0.22+0.25*lvl)))); pPr.set('indent',str(-int(Inches(0.2)))) bu=etree.SubElement(pPr,qn('a:buChar')); bu.set('char','•' if lvl==0 else '–') tot+=est_h(t.replace('::',''),w-0.25*(1+lvl),sz)+gap/72-0.05 if tot>h+0.1: WARN.append(f'slide {CNT[0]} bullets overflow? est {tot:.2f} > {h} ({items[0] if isinstance(items[0],str) else items[0][0]})'[:140]) return tb def arrow(sl,x1,y1,x2,y2,color=GREY,wd=2.25): c=sl.shapes.add_connector(MSO_CONNECTOR.STRAIGHT,Inches(x1),Inches(y1),Inches(x2),Inches(y2)) c.line.color.rgb=rgb(color); c.line.width=Pt(wd) ln=c.line._get_or_add_ln(); t=etree.SubElement(ln,qn('a:tailEnd')); t.set('type','triangle'); t.set('w','med'); t.set('len','med') return c def pic(sl,path,x,y,mw,mh,center=True,name=None): im=Image.open(path); w,h=im.size; r=min(mw/w,mh/h); pw,ph=w*r,h*r px=x+(mw-pw)/2 if center else x; py=y+(mh-ph)/2 if center else y p=sl.shapes.add_picture(path,Inches(px),Inches(py),Inches(pw),Inches(ph)) if name: p.name=name return p,px,py,pw,ph def table(sl,rows,x,y,colw,fs=11,hdr=NAVY,col_fills=None,first_bold=True,hdr_fills=None,hfs=None): nr,nc=len(rows),len(rows[0]); hfs=hfs or fs heights=[] for i,r in enumerate(rows): pt=hfs if i==0 else fs heights.append(max(est_h(c,colw[j],pt,1.18)+0.04 for j,c in enumerate(r))) shp=sl.shapes.add_table(nr,nc,Inches(x),Inches(y),Inches(sum(colw)),Inches(sum(heights))) t=shp.table tblPr=t._tbl.tblPr for a in ('bandRow','firstRow'): tblPr.set(a,'0') sid=tblPr.find(qn('a:tableStyleId')) if sid is not None: sid.text='{5940675A-B579-460E-94D1-54222C63F5DA}' for j,wd in enumerate(colw): t.columns[j].width=Inches(wd) for i,r in enumerate(rows): t.rows[i].height=Inches(heights[i]) for j,c in enumerate(r): cell=t.cell(i,j); cell.margin_left=cell.margin_right=Inches(0.06); cell.margin_top=cell.margin_bottom=Inches(0.02) cell.vertical_anchor=MSO_ANCHOR.MIDDLE tf=cell.text_frame; tf.word_wrap=True for k,line in enumerate(c.split('\n')): p=tf.paragraphs[0] if k==0 else tf.add_paragraph() rr=p.add_run(); rr.text=line; rr.font.name='Calibri'; rr.font.size=Pt(hfs if i==0 else fs) if i==0: rr.font.bold=True; rr.font.color.rgb=rgb('FFFFFF') else: rr.font.color.rgb=rgb('222222'); rr.font.bold=(j==0 and first_bold) if j==0 and first_bold: rr.font.color.rgb=rgb(NAVY) cell.fill.solid() if i==0: cell.fill.fore_color.rgb=rgb((hdr_fills or {}).get(j,hdr)) elif col_fills and j in col_fills: cell.fill.fore_color.rgb=rgb(col_fills[j]) else: cell.fill.fore_color.rgb=rgb(LGREY if i%2==0 else 'FFFFFF') tot=sum(heights) if y+tot>7.0: WARN.append(f'slide {CNT[0]} table bottom {y+tot:.2f} > 7.0') return shp,y+tot SEC={'A':(TEAL,'A Foundations'),'B':(RED,'B Epiglottitis'),'C':(BLUE,'C Croup'),'D':(NAVY,'D Synthesis')} def new(title,sec,src,notes=''): CNT[0]+=1 sl=prs.slides.add_slide(BL); col,lab=SEC[sec] b=sl.shapes.add_shape(MSO_SHAPE.RECTANGLE,0,0,Inches(0.2),Inches(7.5)); b.name='!!Band'; b.fill.solid(); b.fill.fore_color.rgb=rgb(col); b.line.fill.background() tx(sl,title,0.5,0.25,10.5,0.8,size=27,bold=True,color=NAVY,anchor=MSO_ANCHOR.MIDDLE,name='!!Title') bd=box(sl,lab,11.0,0.4,2.1,0.42,fill=col,size=13,bold=True,name='!!Badge') r=sl.shapes.add_shape(MSO_SHAPE.RECTANGLE,Inches(0.5),Inches(1.08),Inches(12.4),Inches(0.04)); r.name='!!Rule'; r.fill.solid(); r.fill.fore_color.rgb=rgb(col); r.line.fill.background() tx(sl,src,0.5,7.08,11.6,0.3,size=9,color=GREY,name='!!Source',italic=True) tx(sl,str(CNT[0]),12.3,7.08,0.7,0.3,size=10,color=GREY,align=PP_ALIGN.RIGHT,name='!!SlideNo') if notes: sl.notes_slide.notes_text_frame.text=notes add_morph(sl) return sl SBs='Scott-Brown Otorhinolaryngology HNS (Vol 2, croup chapter)' # ---------------- 1 TITLE CNT[0]+=1 s=prs.slides.add_slide(BL) bg=s.shapes.add_shape(MSO_SHAPE.RECTANGLE,0,0,prs.slide_width,prs.slide_height); bg.name='!!Band'; bg.fill.solid(); bg.fill.fore_color.rgb=rgb(NAVY); bg.line.fill.background() tx(s,'PAEDIATRIC UPPER AIRWAY EMERGENCIES',0.8,0.9,7.2,0.4,size=14,bold=True,color='8FD3DA',name='!!Badge') tx(s,'Epiglottitis and Acute Laryngotracheobronchitis (Croup)',0.8,1.4,7.2,2.2,size=38,bold=True,color='FFFFFF',name='!!Title') tx(s,'Final-year MBBS seminar: anatomy, pathogenesis, recognition, emergency management, prevention',0.8,3.7,7.0,0.9,size=17,color='D6E4F0') box(s,'Presenter: [Name]\nDepartment of [Paediatrics / ENT]\n[Institution] | [Date]',0.8,5.0,5.6,1.2,fill='2B4F7E',size=15,align=PP_ALIGN.LEFT) box(s,'',8.3,0.7,4.5,6.1,fill='FFFFFF') pic(s,A+'sag_normal.png',8.4,0.8,4.3,5.5,name='!!Airway') tx(s,'Sagittal schematic of the upper airway (original teaching illustration)',8.4,6.3,4.3,0.45,size=10,color=GREY,italic=True,align=PP_ALIGN.CENTER) tx(s,'Textbook-verified content and guideline updates are labelled on each slide. Ghai, Nelson and Dhingra were not available as full text for this deck: cross-check chapter details in your own edition.',0.8,6.5,7.2,0.7,size=10,color='AFC4D8',italic=True) s.notes_slide.notes_text_frame.text='Title slide. Replace presenter placeholders. Transitions: Morph (falls back to Fade in older PowerPoint).' add_morph(s) # ---------------- 2 OBJECTIVES s=new('Learning objectives','A','Structure follows the brief; content sources are tagged slide by slide.','By the end, students should be able to...') objs=[('1','Aetiology and epidemiology','Hib and non-Hib causes of epiglottitis; viral causes, age and season of croup'), ('2','Pathogenesis and anatomical pathology','Supraglottic cellulitis versus subglottic mucosal oedema, and why small changes matter in children'), ('3','Clinical recognition and differential diagnosis','Distinguish epiglottitis, croup, bacterial tracheitis, foreign body, retropharyngeal abscess'), ('4','Investigations and evidence-based management','Airway-first approach to epiglottitis; steroid, epinephrine and Westley-guided care in croup'), ('5','Complications, prevention and prognosis','Hib vaccination, contact prophylaxis, disposition, red flags and outcomes')] for i,(n,t,d) in enumerate(objs): yy=1.35+i*1.1 box(s,n,0.6,yy,0.8,0.95,fill=TEAL,size=28,bold=True,shape=MSO_SHAPE.OVAL if False else MSO_SHAPE.ROUNDED_RECTANGLE) box(s,f'{t}::\n{d}',1.55,yy,7.3,0.95,fill=LGREY,fc='222222',size=14,align=PP_ALIGN.LEFT) box(s,'How to use this deck::\nTags: [TB] checked against a textbook in the library; [GL] guideline or review found online; [K] standard teaching not re-verified here.\n\nSeminar plan (about 30 min):\nFoundations 4 min | Epiglottitis 11 min | Croup 11 min | Synthesis 4 min',9.2,1.35,3.7,5.4,fill=LAMB,fc='222222',size=13,align=PP_ALIGN.LEFT,anchor=MSO_ANCHOR.TOP) # ---------------- 3 INTRO s=new('Introduction and definitions','A','[TB] Rosen\'s Emergency Medicine (epiglottitis, foundations); Tintinalli; Scott-Brown. Mortality figure: Scott-Brown citing a large review.','Both conditions cause acute upper airway obstruction. Emphasise tempo and level.') box(s,'ACUTE EPIGLOTTITIS (supraglottitis)',0.5,1.3,6.05,0.5,fill=RED,size=15,bold=True) box(s,'Invasive bacterial infection causing inflammation and oedema of the epiglottis, aryepiglottic folds, arytenoids and surrounding supraglottic tissue. The swollen tissue can fall over the glottic opening and obstruct the airway.',0.5,1.8,6.05,1.65,fill=LRED,fc='222222',size=13,align=PP_ALIGN.LEFT,anchor=MSO_ANCHOR.TOP) box(s,'ACUTE LARYNGOTRACHEOBRONCHITIS (viral croup)',6.85,1.3,6.05,0.5,fill=BLUE,size=15,bold=True) box(s,'Viral infection of the larynx and trachea (bronchi may be involved) with mucosal oedema, most marked in the subglottis. Syndrome: hoarse voice, barking cough, inspiratory or biphasic stridor, with variable respiratory distress.',6.85,1.8,6.05,1.65,fill=LBLUE,fc='222222',size=13,align=PP_ALIGN.LEFT,anchor=MSO_ANCHOR.TOP) tx(s,'Why they matter together',0.5,3.65,12.4,0.4,size=17,bold=True,color=NAVY) bullets(s,['Relationship:: both produce stridor from acute narrowing of the extrathoracic airway, but they differ in level (supraglottic v subglottic), cause (bacterial v viral), tempo (hours v days) and treatment.', 'Children are predisposed to respiratory failure:: small, compressible airway with high resistance, low functional residual capacity, high oxygen consumption and a short safe apnoea time [TB, Rosen].', 'Croup:: the commonest cause of stridor outside the neonatal period [TB, Tintinalli]; mortality is rare, about 1 in 30,000 cases [TB, Scott-Brown].', 'Epiglottitis:: rare since Hib vaccination, but delayed diagnosis is associated with significantly increased mortality [TB, Rosen]. Croup is a common misdiagnosis.'],0.5,4.05,12.4,2.9,size=14,gap=6) # ---------------- 4 ANATOMY s=new('Detailed upper airway anatomy','A','[TB] Scott-Brown (subglottis narrowest, 6.5 mm example); [K] vertebral levels and cartilage details. Illustration: original schematic.','Walk the airway from the vallecula down to the trachea.') pic(s,A+'sag_normal.png',0.4,1.2,5.6,5.8,name='!!Airway') bullets(s,['Supraglottis:: epiglottis, vallecula, aryepiglottic folds, arytenoids, false (vestibular) folds. Loose submucosa on the epiglottis and folds allows marked oedema [K].', 'Glottis:: true vocal cords and the narrow rima glottidis; the narrowest point in the adult airway [K].', 'Subglottis:: from below the cords to the lower border of the cricoid. The cricoid is the only complete cartilaginous ring, so oedema can only encroach inward.', 'Trachea:: C-shaped cartilage rings with a posterior membranous wall.', 'Paediatric differences::', ('Subglottis is the narrowest part of the child\'s airway [TB, Scott-Brown]; about 6.5 mm in diameter at 18 months',1), ('Larynx sits higher; epiglottis is relatively long and floppy; tongue is relatively large [K]',1), ('Airflow resistance rises with the 4th power of radius reduction (Poiseuille) [TB]',1)],6.2,1.25,6.7,5.7,size=14,gap=5) # ---------------- 5 COMPARISON ANATOMY s=new('Anatomical comparison: normal, epiglottitis, croup','A','Illustration: original schematic (same airway template in all three panels). Correlation of site and symptoms: [TB] Rosen, Scott-Brown; [K].','Supraglottic: muffled voice, drooling, no barking cough. Subglottic: barking cough, hoarseness.') pic(s,A+'three.png',0.4,1.25,8.7,3.8,name='!!Airway') box(s,'Site predicts symptoms::\nSupraglottic swelling blocks swallowing and muffles resonance. Subglottic swelling distorts the vocal cords\' airflow and tracheal mucosa.',9.3,1.3,3.6,3.7,fill=LAMB,fc='222222',size=13,align=PP_ALIGN.LEFT,anchor=MSO_ANCHOR.TOP) box(s,'EPIGLOTTITIS: supraglottic\nMuffled voice, drooling, dysphagia, soft inspiratory stridor, no barking cough. Epiglottis can act as a ball valve: obstructs inspiration, allows expiration [TB].',0.5,5.25,6.1,1.65,fill=LRED,fc='222222',size=13,align=PP_ALIGN.LEFT,line=RED) box(s,'CROUP: subglottic\nBarking cough, hoarseness, inspiratory stridor, no drooling. Narrowest segment, enclosed by the cricoid ring, so oedema narrows the lumen [TB].',6.8,5.25,6.1,1.65,fill=LBLUE,fc='222222',size=13,align=PP_ALIGN.LEFT,line=BLUE) # ---------------- 6 EPIGLOTTITIS DEF/EPI s=new('Epiglottitis: definition, terminology and epidemiology','B','[TB] Rosen\'s Emergency Medicine; [GL] NT Canada CPG "Epiglottitis" (age, onset); [K] Indian schedule: verify against current UIP.','Hib vaccine changed the epidemiology but did not abolish the disease.') bullets(s,['Acute epiglottitis:: acute, life-threatening inflammation of the epiglottis. "Supraglottitis" is the broader term because the aryepiglottic folds, arytenoids and adjacent tissue are involved [TB].', 'Pre-vaccine era:: classic disease of young children (a Canadian CPG states usually 3 to 7 years), with onset to respiratory distress often under 12 hours [GL].', 'After Hib vaccination (1980s onward):: paediatric incidence fell markedly; epiglottitis is now relatively more common in older children and adults [TB, Rosen].', 'Still occurs in vaccinated children:: Hib is still the commonest infectious cause in children and can affect fully immunised ones; non-Hib bacteria also contribute [TB].', 'Adults and adolescents:: often subtle: sore throat out of proportion to findings, anterior neck tenderness. A larger airway needs more swelling to obstruct, but obstruction can still occur [TB].', 'India [K]:: Hib is delivered through the pentavalent vaccine in the national schedule; confirm current schedule and coverage locally.'],0.5,1.3,8.2,5.7,size=14,gap=6) table(s,[['','Pre-Hib vaccine','Current era'],['Typical patient','Child 2 to 7 y','Older child, adolescent, adult'],['Main organism','Hib','Hib (breakthrough), streptococci, S. aureus'],['Onset','Hours','Hours (Hib) to days (others)'],['Airway risk','High','Lower in adults, still real']],9.0,1.4,[1.3,1.35,1.3],fs=11,hdr=RED) box(s,'Teaching point::\nA fully immunised child with drooling and stridor still needs the epiglottitis pathway.',9.0,4.6,3.95,1.5,fill=LAMB,fc='222222',size=13,align=PP_ALIGN.LEFT) # ---------------- 7 AETIOLOGY s=new('Aetiology and microbiology','B','[TB] Rosen\'s Emergency Medicine (organisms, noninfectious causes); [GL] review: S. pneumoniae, S. aureus and beta-haemolytic streptococci recognised in the vaccine era.','Vaccination removes Hib mainly; other organisms and mimics remain.') rows=[['Cause','Frequency / role','Teaching notes'], ['Haemophilus influenzae type b','Classic; still the commonest infectious cause in children [TB]','Encapsulated; invasive disease with bacteraemia [K]; occurs in unvaccinated and rarely in vaccinated children'], ['Other H. influenzae (A, F, non-typeable)','Less frequent [TB]','Not prevented by Hib vaccine'], ['Streptococci (S. pneumoniae, group A beta-haemolytic)','Recognised causes [TB, GL]','Non-Hib bacteria: slower onset, less airway compromise [TB]'], ['Staphylococcus aureus incl. MRSA','Less frequent [TB]','Relevant to empirical cover where MRSA is prevalent [K]'], ['Neisseria meningitidis','Rare [TB]','Consider with petechiae or meningism [K]'], ['Pseudomonas aeruginosa, Candida','Immunocompromised hosts [TB]','Necrotising epiglottitis can occur in immunodeficiency [TB]'], ['Noninfectious mimics','Rare [TB]','Thermal injury (hot liquids, steam), caustic ingestion, allergic reaction, foreign body, irritants, lymphoproliferative disease']] table(s,rows,0.5,1.3,[3.4,3.7,5.3],fs=12,hdr=RED) box(s,'Host factors:: incomplete or absent Hib immunisation, immunodeficiency. Recurrent epiglottitis in an adult warrants immune evaluation [GL].',0.5,6.15,12.4,0.75,fill=LAMB,fc='222222',size=13,align=PP_ALIGN.LEFT) # ---------------- 8 PATHOGENESIS FLOW s=new('Pathogenesis: from colonisation to airway obstruction','B','[TB] Rosen\'s Emergency Medicine (inflammation, ball-valve mechanism); [K] colonisation and bacteraemia steps.','Follow the arrows; each step maps to a symptom.') steps=[('1 Entry','Droplet spread; nasopharyngeal colonisation by Hib [K]'), ('2 Invasion','Mucosal invasion, local infection, often bacteraemia [K]'), ('3 Cellulitis','Neutrophilic inflammation of epiglottis, AE folds, arytenoids [TB, K]'), ('4 Oedema','Supraglottic tissues swell and distend [TB]')] steps2=[('5 Displacement','Swollen epiglottis and folds protrude over the glottic opening; ball-valve effect [TB]'), ('6 Narrowing','Turbulent inspiratory airflow: stridor. Pooled secretions: drooling [TB, K]'), ('7 Fatigue','Rising work of breathing, hypoxaemia, hypercarbia [K]'), ('8 Obstruction','Sudden complete obstruction, respiratory arrest [TB, K]')] for i,(a,b) in enumerate(steps): xx=0.5+i*3.15; box(s,f'{a}::\n{b}',xx,1.45,2.75,1.75,fill=LRED,fc='222222',size=13,line=RED,align=PP_ALIGN.LEFT,anchor=MSO_ANCHOR.TOP) if i<3: arrow(s,xx+2.78,2.3,xx+3.12,2.3,RED) arrow(s,12.1,3.25,12.1,3.55,RED); arrow(s,12.1,3.55,0.9,3.55,RED,1.5); arrow(s,0.9,3.55,0.9,3.85,RED) for i,(a,b) in enumerate(steps2): xx=0.5+i*3.15; box(s,f'{a}::\n{b}',xx,3.85,2.75,1.75,fill=('F8C9C4' if i<3 else RED),fc=('222222' if i<3 else 'FFFFFF'),size=13,line=RED,align=PP_ALIGN.LEFT,anchor=MSO_ANCHOR.TOP) if i<3: arrow(s,xx+2.78,4.7,xx+3.12,4.7,RED) box(s,'Clinical mapping:: fever and toxicity = infection/bacteraemia; sore throat and dysphagia = inflamed supraglottis; muffled voice and drooling = swollen epiglottis and folds; stridor and tripod posture = narrowed inlet. Deterioration can be abrupt.',0.5,5.85,12.4,1.05,fill=LAMB,fc='222222',size=13,align=PP_ALIGN.LEFT) # ---------------- 9 PATHOLOGY s=new('Pathology and anatomical changes','B','[TB] Rosen\'s Emergency Medicine (radiographic signs, Fig. 162.5). Images: PMC-derived clinical images via Orris image library (laryngoscopy, radiograph); original schematic at left.','Correlate the picture with the symptoms.') pic(s,A+'sag_epi.png',0.4,1.2,4.7,5.75,name='!!Airway') _,px,py,pw,ph=pic(s,A+'epi_laryngo.jpg',5.3,1.25,3.75,2.5) tx(s,'Laryngoscopy: diffuse erythema and oedema of epiglottis and AE folds',5.3,3.75,3.75,0.5,size=10,color=GREY,italic=True) pic(s,A+'epi_xray.jpg',9.3,1.25,3.6,2.5) tx(s,'Lateral neck: thumbprint sign, supraglottic narrowing',9.3,3.75,3.6,0.5,size=10,color=GREY,italic=True) bullets(s,['Macroscopic:: swollen, rounded, cherry-red epiglottis; thickened, oedematous AE folds and arytenoids; vallecula obliterated [TB, GL].', 'Microscopic:: neutrophilic infiltrate, vascular congestion, submucosal oedema [K].', 'Effect on airway:: reduced supraglottic calibre; tissue collapses over the glottis on inspiration [TB].', 'Radiograph (only if stable):: thumbprint epiglottis, thickened AE folds, absent vallecula air, dilated hypopharynx. Rosen notes a substantial proportion can have normal films, so a normal film never excludes it [TB].'],5.3,4.25,7.6,2.75,size=13,gap=4) # ---------------- 10 HISTORY s=new('Clinical features: history','B','[TB] Rosen\'s Emergency Medicine; Tintinalli; [K] mechanisms.','Classic triad in a young child: drooling, dysphagia, distress.') rows=[['Feature','Typical finding','Why it happens'], ['Onset','Abrupt, over hours; often little or no preceding cold [K]','Rapid bacterial cellulitis of supraglottis'], ['Fever','High, with toxicity [TB]','Invasive bacterial infection, bacteraemia'], ['Sore throat','Severe; in adults often out of proportion to findings [TB]','Inflamed, tender supraglottic mucosa'], ['Dysphagia and odynophagia','Refuses food and fluid','Swallowing across an inflamed, swollen inlet'], ['Drooling','Prominent; cannot handle secretions [TB]','Cannot swallow saliva'], ['Voice','Muffled ("hot potato") rather than hoarse [K]','Swollen supraglottic resonating space'], ['Cough','Usually absent [TB, Tintinalli]','Glottic and subglottic mucosa spared'], ['Respiratory distress','Progressive; may begin with stridor [TB]','Narrowing of the laryngeal inlet'], ['Preceding symptoms','Minimal URI at most; sudden change in a well child [K]','Contrast with croup\'s 1 to 3 day prodrome']] table(s,rows,0.5,1.3,[2.6,5.4,4.4],fs=12,hdr=RED) # ---------------- 11 EXAMINATION s=new('Clinical features: examination','B','[TB] Rosen\'s Emergency Medicine; Tintinalli (tripod/sniffing posture); [K] soft low-pitched stridor and late signs.','Observe from a distance. Do not examine the throat.') bullets(s,['General:: toxic, anxious, febrile child sitting still [TB].', 'Posture:: tripod or sniffing position, neck extended, chin forward and jaw jutting to maximise the airway [TB].', 'Drooling and silence:: no cough, little phonation, voice muffled [TB].', 'Breathing:: tachypnoea, soft inspiratory stridor (often quieter than in croup), suprasternal and subcostal retractions [K].', 'Perfusion and mentation:: tachycardia; restlessness progressing to lethargy.', 'Children v adults::', ('Young children: dramatic obstruction, drooling, toxicity',1), ('Adolescents and adults: sore throat out of proportion, anterior neck tenderness, often no stridor [TB]',1)],0.5,1.3,7.4,5.6,size=14,gap=5) box(s,'PARTICULARLY CONCERNING',8.2,1.3,4.7,0.5,fill=RED,size=15,bold=True) box(s,'Drooling with stridor:: inlet already critically narrowed.\nRefusal to lie down:: position keeps the epiglottis forward.\nFalling effort or quiet child:: exhaustion, not improvement.\nCyanosis, altered consciousness, bradycardia:: late, pre-arrest signs.\nAny agitation:: crying can precipitate complete obstruction.',8.2,1.8,4.7,5.0,fill=LRED,fc='222222',size=13,align=PP_ALIGN.LEFT,anchor=MSO_ANCHOR.TOP,line=RED) # ---------------- 12 COURSE s=new('Clinical course and complications','B','[TB] Rosen\'s Emergency Medicine (non-Hib slower, epiglottic abscess, necrotising form, delayed diagnosis); [K] systemic and iatrogenic complications.','Not every patient follows the same path.') tl=[('0 h','Sore throat, fever'),('2 to 6 h','Dysphagia, drooling, muffled voice'),('Hours','Stridor, tripod, retractions'),('Without airway','Hypoxaemia, exhaustion, arrest')] for i,(a,b) in enumerate(tl): xx=0.5+i*3.15; box(s,f'{a}\n{b}',xx,1.35,2.75,1.0,fill=[ '#'][0] and ['F8C9C4','F3A9A0','E57368',RED][i],fc=('222222' if i<2 else 'FFFFFF'),size=13,bold=False) if i<3: arrow(s,xx+2.78,1.85,xx+3.12,1.85,RED) tx(s,'Illustrative time course in a young child with Hib; tempo varies widely [K].',0.5,2.4,12.4,0.35,size=11,color=GREY,italic=True) tx(s,'Complications',0.5,2.8,6,0.4,size=17,bold=True,color=NAVY) bullets(s,['Complete airway obstruction, hypoxaemia, respiratory arrest, hypoxic brain injury or death [TB, K]', 'Epiglottic abscess (especially adolescents) [TB]', 'Necrotising epiglottitis in immunodeficiency [TB]', 'Bacteraemia and sepsis; pneumonia, meningitis, septic arthritis, cellulitis from invasive Hib [K]', 'Post-obstructive pulmonary oedema after relief of obstruction [K]', 'Airway-related: accidental extubation, subglottic injury [K]'],0.5,3.2,6.6,3.7,size=13,gap=4) tx(s,'Factors linked with severe disease',7.4,2.8,5.5,0.4,size=17,bold=True,color=NAVY) bullets(s,['Young age (small airway) [TB]','Delayed diagnosis: significantly increased mortality [TB]','Agitation or airway manipulation without a plan [K]','Hib as the pathogen: faster onset; non-Hib bacteria tend to be slower [TB]','Immunocompromise [TB]'],7.4,3.2,5.5,2.5,size=13,gap=4) box(s,'Avoid assuming a typical timeline: an adolescent can present with only a sore throat and still need ICU observation.',7.4,5.75,5.5,1.1,fill=LAMB,fc='222222',size=12,align=PP_ALIGN.LEFT) # ---------------- 13 DIAGNOSIS & DDx s=new('Diagnosis and differential diagnosis','B','[TB] Tintinalli Table 126-2 (common acquired causes of stridor), Rosen (bacterial tracheitis, foreign body, imaging limits); [K] retropharyngeal and peritonsillar details.','Diagnosis is clinical. Tests come after the airway is safe.') bullets(s,['Recognition:: abrupt fever, drooling, muffled voice, tripod posture, toxic appearance. Treat on suspicion.', 'Labs (after airway secured):: blood culture, FBC/CRP; epiglottic culture at intubation. They never justify delay [TB, K].', 'Imaging (only if stable, accompanied by an airway-skilled clinician):: lateral neck film may show thumbprint sign; a normal film does not exclude disease [TB].'],0.5,1.2,12.4,1.65,size=13,gap=3) rows=[['','Epiglottitis','Croup','Bacterial tracheitis','Retropharyngeal abscess','Peritonsillar abscess','Foreign body'], ['Onset','Hours','1 to 3 days','URI then rapid toxicity','Days','Days','Sudden choking'], ['Fever','High','None or low','High','Yes','Yes','No'], ['Cough','Absent','Barking','Croupy, productive','Variable','Absent','Sudden, paroxysmal'], ['Drooling / posture','Drooling, tripod','None','None','Drooling, torticollis, neck stiffness','Drooling, trismus','Variable'], ['Key clue','Thumbprint; toxic','Steeple sign; non-toxic','Poor response to croup therapy; S. aureus','Prevertebral widening / CT','Uvula deviation','History; bronchoscopy; film may be normal']] table(s,rows,0.5,2.95,[1.5,1.7,1.5,1.9,2.0,1.8,2.0],fs=11,hdr=RED,hdr_fills={2:BLUE}) # ---------------- 14 PRECAUTIONS s=new('Airway precautions in suspected epiglottitis','B','[TB] Rosen\'s Emergency Medicine (do not reposition or move a stable patient for tests; controlled setting; consult airway experts early); [K] equipment list.','Make this the slide students remember.') box(s,'SUSPECTED EPIGLOTTITIS IS AN AIRWAY EMERGENCY',0.5,1.3,12.4,0.85,fill=RED,size=26,bold=True) box(s,'DO',0.5,2.35,6.05,0.5,fill=GREEN,size=16,bold=True) box(s,'Keep the child calm, in the parent\'s arms, in the position of comfort\nCall the most experienced anaesthetist, ENT surgeon and paediatrician now\nGive oxygen only in a way the child tolerates; monitor non-invasively\nTransfer with an airway-skilled clinician to a controlled, equipped setting (usually theatre) [TB]\nPrepare a difficult-airway set: smaller tubes, bougie, rigid bronchoscope, surgical airway tray [K]',0.5,2.85,6.05,3.45,fill=LGREEN,fc='222222',size=13,align=PP_ALIGN.LEFT,anchor=MSO_ANCHOR.TOP) box(s,'DO NOT',6.85,2.35,6.05,0.5,fill=RED,size=16,bold=True) box(s,'Lay the child supine or force a position\nUse a tongue depressor or examine the throat in an unstable child\nDistress the child: cannulation, bloods, separation from parent, before the airway is secured\nSend to radiology or ward unaccompanied\nSedate without the airway team present\nDelay the airway for imaging or laboratory results [TB]',6.85,2.85,6.05,3.45,fill=LRED,fc='222222',size=13,align=PP_ALIGN.LEFT,anchor=MSO_ANCHOR.TOP) box(s,'Airway examination and intervention must be planned by experienced clinicians in an appropriately equipped setting.',0.5,6.4,12.4,0.55,fill=LAMB,fc='222222',size=13,bold=True) # ---------------- 15 EMERGENCY MGMT s=new('Emergency management of epiglottitis: stepwise flowchart','B','[TB] Rosen\'s Emergency Medicine (airway first; bag-mask then intubation, needle cricothyroidotomy or tracheostomy; intubated 3 to 5 days; cephalosporin); [K] details of induction.','Airway stabilisation has priority over every diagnostic procedure.') st=[('1 Recognise suspected epiglottitis','Treat on clinical suspicion: abrupt fever, drooling, muffled voice, tripod posture. Waiting for proof risks sudden obstruction.'), ('2 Call anaesthesia, ENT, paediatrics now','The airway may be difficult; it needs the most experienced operators and a surgical back-up plan [TB].'), ('3 Minimise agitation; position of comfort','Crying and struggling increase effort and can precipitate complete obstruction. Keep the child with the parent.'), ('4 Monitor; oxygen as tolerated','Pulse oximetry and observation. Blow-by oxygen held by the parent; do not force a mask on a distressed child.'), ('5 Secure the airway in a controlled setting','Usually theatre: anaesthetist-led induction with ENT ready for rigid bronchoscopy or tracheostomy. If unstable: bag-mask ventilation, then intubation, then needle cricothyroidotomy or tracheostomy [TB].'), ('6 Start IV antimicrobials','Cover Hib and other pathogens (next slide). Give once airway is secure, or earlier if it causes no distress; take cultures after the airway is safe.'), ('7 Supportive care and intensive monitoring','Patients often remain intubated 3 to 5 days while antibiotics settle the oedema [TB]; fluids, antipyretics, planned extubation.')] for i,(a,b) in enumerate(st): yy=1.28+i*0.8 box(s,a,0.5,yy,4.2,0.72,fill=(RED if i==4 else '8E2B24' if i<4 else NAVY),size=14,bold=True,align=PP_ALIGN.LEFT) box(s,b,4.85,yy,8.05,0.72,fill=LRED if i!=4 else 'F8C9C4',fc='222222',size=12,align=PP_ALIGN.LEFT) if i<6: arrow(s,2.6,yy+0.72,2.6,yy+0.8,RED,2) # ---------------- 16 ANTIBIOTICS s=new('Antibiotics and supportive treatment','B','[TB] Rosen (second- or third-generation cephalosporin); [GL] review (ceftriaxone, cefotaxime, ampicillin-sulbactam; alternatives in beta-lactam allergy); [GL] NT CPG (cefuroxime); [GL] Sawyer 1994 RCT (ceftriaxone). Doses are examples: verify against your local guideline.','Duration was not verified against a named guideline: check local protocol.') rows=[['Option','Rationale','Dose reported in source'], ['Ceftriaxone or cefotaxime

cd /tmp/workspace/epiglottitis-croup && python - <<'PY' t=open('src/build.py').read() i=t.index("s=new('Summary and high-yield clinical pearls'") open('src/build.py','w').write(t[:i]) print(len(t[:i].splitlines())) PY cat >> src/build.py <<'EOF' s=new('Summary and high-yield clinical pearls','D','Synthesis of slides 1 to 33.','Close with the two-sentence rule: calm child with barking cough gets steroid; toxic drooling child gets the airway team.') cards=[('Anatomy','Epiglottitis: supraglottic.\nCroup: subglottic (cricoid, narrowest in children).',NAVY), ('Distinguish','Epiglottitis: abrupt, toxic, drooling, muffled, no cough.\nCroup: URI, barking cough, hoarse, non-toxic.',TEAL), ('Red flags','Tripod posture, drooling, cyanosis, drowsiness, fatigue, stridor at rest, quiet chest, poor response to treatment.',RED), ('Emergency principles','Airway first. Calm child. Senior airway team. No throat exam, no supine, no delay for tests.',AMBER), ('Treatment','Epiglottitis: secure airway, IV cephalosporin, ICU.\nCroup: dexamethasone, nebulised epinephrine if moderate to severe, observe, oxygen.',BLUE), ('Prevention and outcome','Hib vaccine and contact prophylaxis when Hib isolated. Croup is mostly self-limited; death is rare.',PURPLE)] for i,(h,d,c) in enumerate(cards): x=0.6+(i%3)*4.1; y=1.4+(i//3)*2.8 box(s,x,y,3.9,0.55,h,c,WHITE,16,True,shape=MSO_SHAPE.RECTANGLE) box(s,x,y+0.55,3.9,2.0,d,LIGHT,DARK,13.5,shape=MSO_SHAPE.RECTANGLE,anchor=MSO_ANCHOR.TOP) # ---------------- refs s=new('References (1 of 2)','R','Source-verification statement on the next slide.','Textbooks verified in library text are listed first.') bullets(s,['Scott-Brown\'s Otorhinolaryngology Head & Neck Surgery, Vol 2 (ISBN 9781138094634). Croup (acute laryngotracheobronchitis), Table 29.1 and Figure 29.1.', 'Tintinalli\'s Emergency Medicine: A Comprehensive Study Guide (ISBN 9781260019933). Croup; Tables 126-2 and 126-3.', 'Rosen\'s Emergency Medicine: Concepts and Clinical Practice (ISBN 9780323757898). Upper airway infections in children, including epiglottitis; Figures 162.5 and 162.6.', 'The Harriet Lane Handbook, 23rd ed (ISBN 9780323876988). Dexamethasone dosing entry.', 'Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child 1978;132:484-7.', 'Russell KF, Liang Y, O\'Gorman K, Johnson DW, Klassen TP. Glucocorticoids for croup. Cochrane Database Syst Rev 2011;(1):CD001955.', 'Bjornson C, Russell KF, Vandermeer B, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev 2011;(2):CD006619.', 'Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med 2004;351:1306-13.'],0.6,1.35,12.2,5.6,13.5,gap=6) s=new('References (2 of 2) and source verification','R','Figures: schematic diagrams created for this seminar; clinical images from Orris medical image library.','Be transparent about what was and was not verified.') bullets(s,['Sawyer SM, et al. Successful treatment of epiglottitis with two doses of ceftriaxone. PubMed PMID 8129435 (1994).', 'NHS Highland. Croup (paediatric guidelines), Right Decisions website (web, accessed Nov 2026). Dexamethasone, budesonide and epinephrine doses.', 'Northwest Territories Health and Social Services. Epiglottitis, pediatric clinical practice guideline (web). Age range, cefuroxime dose, rifampin.', 'Medscape (emedicine). Epiglottitis treatment and management; ScienceDirect Topics, Acute epiglottitis (secondary overviews: antibiotic options, rifampin criteria).', 'AMBOSS. Croup (secondary summary: Westley cut-offs, observation after epinephrine).', 'Khalid A, et al. Low-dose (0.15 mg/kg) versus high-dose (0.6 mg/kg) dexamethasone for paediatric croup. Front Pediatr 2026, PMID 42698708 (identified in a recent-evidence search; full text not reviewed).'],0.6,1.35,12.2,3.4,12.5,gap=5) box(s,0.6,4.85,12.2,2.1,'Source-verification statement||\nGhai Essential Pediatrics, Nelson Textbook of Pediatrics and Dhingra\'s Diseases of Ear, Nose and Throat were not accessible in full text for this presentation and have not been quoted or verified. Content tagged "verified" comes from the library textbooks above; web guideline content is labelled as such. Statements marked "standard teaching" are general knowledge not checked against a named text. Cross-check chapters and doses in your own editions and local guideline. Doses are for teaching only.','FFF4DD',DARK,12.5,anchor=MSO_ANCHOR.TOP,line=AMBER) prs.save('output/Epiglottitis_and_Croup_Seminar.pptx') print('slides',len(prs.slides)) for w in WARN: print('WARN',w) EOF python src/build.py

cd /tmp/workspace/epiglottitis-croup && python - <<'EOF' from pptx import Presentation from pptx.util import Emu p=Presentation('output/Epiglottitis_and_Croup_Seminar.pptx') for i,s in enumerate(p.slides,1): for sh in s.shapes: b=(sh.top+sh.height)/914400; r=(sh.left+sh.width)/914400 if sh.name in('Footer','SlideNo','SideBar'): continue if b>7.05 or r>13.2: print(i,sh.name,sh.shape_type,round(b,2),round(r,2)) print(len(p.slides)) import zipfile; z=zipfile.ZipFile('output/Epiglottitis_and_Croup_Seminar.pptx'); x=z.read('ppt/slides/slide5.xml').decode(); print(x[-700:]) EOF

cd /tmp/workspace/epiglottitis-croup/src && python - <<'EOF' s=open('build.py').read() i=s.rfind("rows=[['Option','Rationale'") print(len(s),i) open('part1.py','w').write(s[:i]) EOF tail -c 600 part1.py; python -c "import ast;ast.parse(open('/tmp/workspace/epiglottitis-croup/src/part1.py').read());print('syntax ok')"

~/epiglottitis-croup/src/part2.py

cd /tmp/workspace/epiglottitis-croup && cat src/part1.py src/part2.py > src/full.py && python src/full.py 2>&1 | tail -40

cd /tmp/workspace/epiglottitis-croup && sed -i "s/size=27,bold=True,color=NAVY,anchor=MSO_ANCHOR.MIDDLE,name='!!Title'/size=24,bold=True,color=NAVY,anchor=MSO_ANCHOR.MIDDLE,name='!!Title'/" src/part1.py && cat src/part1.py src/part2.py > src/full.py && python src/full.py 2>&1 | tail -8 && python - <<'EOF' from pptx import Presentation from pptx.util import Emu p=Presentation('output/Epiglottitis_and_Croup_Seminar.pptx') W,H=p.slide_width,p.slide_height; bad=0 for i,s in enumerate(p.slides,1): for sh in s.shapes: if sh.left is None: continue if sh.left<0 or sh.top<0 or sh.left+sh.width>W+10 or sh.top+sh.height>H+10: print('OUT',i,sh.name,round(sh.left/914400,2),round(sh.top/914400,2),round((sh.left+sh.width)/914400,2),round((sh.top+sh.height)/914400,2)); bad+=1 x=s._element.xml assert 'p159:morph' in x print('bounds issues',bad,'| morph on all',len(p.slides),'slides') EOF ls -la output