"anaphylaxis" AND "guidelines"

anaphylaxis guidelines 2024 2025 WAO AAAAI epinephrine management update

https://www.ccjm.org/content/89/2/106

mkdir -p /home/daytona/workspace/anaphylaxis-ppt && ls /home/daytona/workspace/a…

~/anaphylaxis-ppt/build.js

const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Anaphylaxis: Recognition, Management & 2024 Guidelines";
pres.author = "Medical Education";

// ── COLOR PALETTE ────────────────────────────────────────
const C = {
  navy:    "0A1628",   // dominant dark bg
  crimson: "C0392B",   // accent / danger
  teal:    "1A7A6E",   // second accent / positive
  amber:   "E67E22",   // warning highlight
  white:   "FFFFFF",
  lightBg: "F4F7FA",   // section bg
  silver:  "BDC3C7",
  textDark:"1C2833",
  cardBg:  "1F3247",   // card on dark bg
};

// ── HELPERS ──────────────────────────────────────────────
function darkSlide(slide) {
  slide.background = { color: C.navy };
}
function lightSlide(slide) {
  slide.background = { color: C.lightBg };
}
function sectionHeader(slide, label, color) {
  slide.addShape(pres.ShapeType.rect, { x:0, y:0, w:10, h:0.55, fill:{ color } });
  slide.addText(label, { x:0.3, y:0.06, w:9.4, h:0.42, fontSize:13, bold:true, color:C.white, margin:0 });
}
function slideTitle(slide, text, color, y=0.62) {
  slide.addText(text, { x:0.35, y, w:9.3, h:0.7, fontSize:22, bold:true, color, margin:0 });
}
function accent(slide, x, y, w, h, color) {
  slide.addShape(pres.ShapeType.rect, { x, y, w, h, fill:{ color }, line:{color, pt:0} });
}

// ── HELPER: bulletBox ────────────────────────────────────
function bulletBox(slide, items, opts={}) {
  const {x=0.35, y=1.4, w=9.3, h=3.7, fontSize=13.5, color=C.textDark, indent=0.3, bold=false} = opts;
  const lines = items.flatMap((it, i) => {
    if (typeof it === "string") {
      return [{ text: it, options:{ bullet:{ indent }, fontSize, color, bold, breakLine: i<items.length-1 } }];
    }
    // {head, sub:[...]}
    const arr = [{ text: it.head, options:{ bullet:{ indent }, fontSize, color, bold:true, breakLine:true } }];
    it.sub.forEach((s,si) => arr.push({ text: s, options:{ bullet:{ indent:indent+0.25 }, fontSize:fontSize-1, color, breakLine: si<it.sub.length-1 } }));
    return arr;
  });
  slide.addText(lines, { x, y, w, h, valign:"top", margin:4, paraSpaceAfter:2 });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 1 — TITLE
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  darkSlide(s);
  // bold red bar
  accent(s, 0, 0, 10, 0.18, C.crimson);
  // bottom bar
  accent(s, 0, 5.43, 10, 0.19, C.teal);

  s.addText("ANAPHYLAXIS", {
    x:0.4, y:0.55, w:9.2, h:1.3, fontSize:54, bold:true, color:C.white,
    charSpacing:6, align:"center"
  });
  s.addText("Recognition · Management · Latest 2024 Guidelines", {
    x:0.4, y:1.85, w:9.2, h:0.55, fontSize:20, color:C.silver, align:"center", italic:true
  });

  // divider line
  accent(s, 1.5, 2.52, 7, 0.06, C.crimson);

  s.addText([
    { text: "AAAAI / ACAAI 2023 Practice Parameter Update  ", options:{ bold:true, color:C.amber } },
    { text: "| WAO 2024 Criteria | AHA 2024 First Aid Guidelines", options:{ color:C.silver } }
  ], { x:0.4, y:2.72, w:9.2, h:0.5, fontSize:12.5, align:"center" });

  s.addText("For Clinicians & Residents — July 2026", {
    x:0.4, y:5.1, w:9.2, h:0.35, fontSize:11, color:C.silver, align:"center", italic:true
  });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 2 — OVERVIEW / CONTENTS
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  darkSlide(s);
  accent(s, 0, 0, 10, 0.55, C.teal);
  s.addText("CONTENTS", { x:0.35, y:0.08, w:9.3, h:0.38, fontSize:16, bold:true, color:C.white, margin:0 });

  const topics = [
    ["01", "Definition & Pathophysiology"],
    ["02", "Epidemiology & Common Triggers"],
    ["03", "Diagnostic Criteria (WAO 2024 / NIAID)"],
    ["04", "Clinical Presentation — Organ Systems"],
    ["05", "Risk Stratification & Severity Grading"],
    ["06", "Differential Diagnosis"],
    ["07", "Immediate Management Algorithm"],
    ["08", "Pharmacotherapy — Epinephrine (First-Line)"],
    ["09", "Adjunct Therapies — Antihistamines & Steroids"],
    ["10", "Biphasic Anaphylaxis & Observation Period"],
    ["11", "Special Populations"],
    ["12", "Self-Injectable Epinephrine & Discharge Planning"],
    ["13", "Long-Term Prevention & Immunotherapy"],
    ["14", "Key 2024 Guideline Updates"],
    ["15", "References"],
  ];

  const col1 = topics.slice(0,8);
  const col2 = topics.slice(8);

  col1.forEach(([num,title], i) => {
    const y = 0.72 + i*0.58;
    accent(s, 0.35, y+0.06, 0.42, 0.34, C.crimson);
    s.addText(num, { x:0.35, y:y+0.04, w:0.42, h:0.34, fontSize:11, bold:true, color:C.white, align:"center", margin:0 });
    s.addText(title, { x:0.88, y, w:3.8, h:0.45, fontSize:12, color:C.white, valign:"middle", margin:0 });
  });
  col2.forEach(([num,title], i) => {
    const y = 0.72 + i*0.58;
    accent(s, 5.15, y+0.06, 0.42, 0.34, C.amber);
    s.addText(num, { x:5.15, y:y+0.04, w:0.42, h:0.34, fontSize:11, bold:true, color:C.white, align:"center", margin:0 });
    s.addText(title, { x:5.68, y, w:3.9, h:0.45, fontSize:12, color:C.white, valign:"middle", margin:0 });
  });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 3 — DEFINITION & PATHOPHYSIOLOGY
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionHeader(s, "DEFINITION & PATHOPHYSIOLOGY", C.navy);
  slideTitle(s, "What Is Anaphylaxis?", C.navy);

  // definition box
  accent(s, 0.35, 1.42, 9.3, 0.02, C.crimson);
  s.addShape(pres.ShapeType.rect, { x:0.35, y:1.44, w:9.3, h:1.0, fill:{ color:"FFE8E6" }, line:{color:"FFE8E6",pt:0} });
  s.addText(
    "Anaphylaxis is a serious, potentially life-threatening systemic hypersensitivity reaction that arises when mast cells and basophils release potent vasoactive mediators affecting the cardiovascular, cutaneous, respiratory, and gastrointestinal systems simultaneously.",
    { x:0.55, y:1.48, w:8.9, h:0.9, fontSize:12.5, color:C.textDark, italic:true }
  );

  s.addText("Mechanism", { x:0.35, y:2.56, w:9.3, h:0.35, fontSize:14, bold:true, color:C.navy });
  bulletBox(s, [
    { head:"IgE-Mediated (Allergic)", sub:["Multivalent allergen cross-links IgE bound to FcεRI on mast cells/basophils","Triggers degranulation → release of histamine, tryptase, PGD₂, LTC₄, PAF"] },
    { head:"Non-IgE-Mediated (Anaphylactoid)", sub:["Direct mast cell activation (radiocontrast, opioids, vancomycin)","Complement activation (C3a, C5a anaphylatoxins)"] },
    { head:"Key Mediators & Effects", sub:["Histamine/leukotrienes → vasodilation, increased permeability, bronchoconstriction","Tryptase → marker for mast cell activation (peaks 1–2 h post-reaction)","PAF → cardiac depression, thrombosis"] },
  ], { x:0.35, y:2.9, w:9.3, h:2.65, fontSize:12.5 });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 4 — EPIDEMIOLOGY & TRIGGERS
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionHeader(s, "EPIDEMIOLOGY & TRIGGERS", C.navy);
  slideTitle(s, "How Common Is It & What Causes It?", C.navy);

  // stat cards
  const stats = [
    { n:"2–8%", label:"Lifetime incidence\nin adults" },
    { n:"~1500–2000", label:"Annual deaths in\nthe USA" },
    { n:"<1%", label:"Fatal cases among\nall anaphylaxis events" },
    { n:"~50%", label:"Reactions occur\nat home" },
  ];
  stats.forEach((st, i) => {
    const x = 0.35 + i*2.4;
    s.addShape(pres.ShapeType.rect, { x, y:1.42, w:2.2, h:1.4, fill:{ color:C.navy }, line:{color:C.navy,pt:0}, shadow:{type:"outer",blur:5,offset:2,angle:45,color:"888888"} });
    s.addText(st.n, { x, y:1.5, w:2.2, h:0.7, fontSize:22, bold:true, color:C.amber, align:"center" });
    s.addText(st.label, { x, y:2.18, w:2.2, h:0.58, fontSize:10.5, color:C.white, align:"center" });
  });

  // trigger table — two columns
  s.addText("Common Triggers", { x:0.35, y:2.95, w:9.3, h:0.35, fontSize:14, bold:true, color:C.navy });

  const left = [
    ["IgE-Mediated", "Foods (peanut, tree nut, shellfish, milk, egg)"],
    ["","Insect venom (bee, wasp, fire ant)"],
    ["","Drugs (beta-lactam antibiotics, NSAIDs)"],
    ["","Latex / allergen immunotherapy"],
  ];
  const right = [
    ["Non-IgE-Mediated","Radiocontrast media (non-IgE, idiosyncratic)"],
    ["","Opioids, vancomycin (direct mast cell release)"],
    ["","NSAIDs via COX-1 inhibition"],
    ["Idiopathic","No identifiable trigger in ~20% of cases"],
  ];

  const mkRows = (rows) => rows.map(([cat, val]) => [
    { text: cat, options:{ bold:!!cat, fontSize:11, color:C.white, fill:{ color: cat ? C.teal : C.cardBg } } },
    { text: val, options:{ fontSize:11, color:C.white, fill:{ color:C.cardBg } } },
  ]);

  s.addTable(mkRows(left), { x:0.35, y:3.35, w:4.55, colW:[1.25,3.3], rowH:0.36, border:{pt:1,color:"2A4A6A"} });
  s.addTable(mkRows(right), { x:5.1, y:3.35, w:4.55, colW:[1.35,3.2], rowH:0.36, border:{pt:1,color:"2A4A6A"} });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 5 — DIAGNOSTIC CRITERIA (WAO / NIAID 2024)
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionHeader(s, "DIAGNOSTIC CRITERIA", C.crimson);
  slideTitle(s, "WAO 2024 / NIAID-FAAN Clinical Criteria", C.navy);

  s.addText("Anaphylaxis is HIGHLY LIKELY when ANY ONE of the following criteria is met:", {
    x:0.35, y:1.38, w:9.3, h:0.4, fontSize:12.5, bold:true, color:C.crimson
  });

  const criteria = [
    {
      num:"1",
      head:"Acute onset (minutes to hours) with skin/mucosal involvement PLUS at least one of:",
      items:["Respiratory compromise (dyspnea, wheeze, stridor, hypoxia)","Reduced BP or end-organ dysfunction (syncope, incontinence)"],
    },
    {
      num:"2",
      head:"Two or more of the following after exposure to a LIKELY allergen (rapid onset):",
      items:["Skin/mucosal involvement","Respiratory compromise","Reduced BP / end-organ dysfunction","Persistent GI symptoms (cramping, vomiting)"],
    },
    {
      num:"3",
      head:"Reduced BP after exposure to a KNOWN allergen for that patient:",
      items:["Adults: systolic <90 mmHg or >30% drop from baseline","Infants/children: age-specific low BP or >30% drop in systolic"],
    },
  ];

  criteria.forEach((cr, i) => {
    const y = 1.84 + i*1.2;
    accent(s, 0.35, y, 0.42, 0.42, i===0?C.crimson:i===1?C.teal:C.amber);
    s.addText(cr.num, { x:0.35, y:y+0.03, w:0.42, h:0.38, fontSize:16, bold:true, color:C.white, align:"center", margin:0 });
    s.addText(cr.head, { x:0.88, y, w:8.75, h:0.42, fontSize:12, bold:true, color:C.textDark, valign:"middle" });
    const subLines = cr.items.map((it,si) => ({
      text: it,
      options:{ bullet:{ indent:0.25 }, fontSize:11.5, color:C.textDark, breakLine: si<cr.items.length-1 }
    }));
    s.addText(subLines, { x:0.9, y:y+0.43, w:8.7, h:0.7, valign:"top" });
  });

  s.addShape(pres.ShapeType.rect, { x:0.35, y:5.18, w:9.3, h:0.38, fill:{ color:C.navy }, line:{color:C.navy,pt:0} });
  s.addText("Note: Epinephrine is appropriate even when criteria are not fully met if allergen exposure occurs with ANY systemic symptom.", {
    x:0.5, y:5.22, w:9.0, h:0.3, fontSize:10.5, color:C.amber, italic:true
  });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 6 — CLINICAL PRESENTATION
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionHeader(s, "CLINICAL PRESENTATION", C.navy);
  slideTitle(s, "Organ System Manifestations", C.navy);

  const systems = [
    { sys:"Cutaneous\n(~90%)", items:["Urticaria, flushing, pruritus","Angioedema (face, lips, tongue)","Erythema / morbilliform rash"], col:C.crimson },
    { sys:"Respiratory\n(~70%)", items:["Bronchospasm, wheezing","Stridor (laryngeal edema)","Rhinorrhea, hoarseness"], col:C.teal },
    { sys:"Cardiovascular\n(~45%)", items:["Hypotension, tachycardia","Arrhythmias","Chest pain, palpitations"], col:C.amber },
    { sys:"GI (~45%)", items:["Nausea, vomiting","Abdominal cramps, diarrhea"], col:"7D3C98" },
    { sys:"Neurological", items:["Anxiety, dizziness","Syncope, altered consciousness","Seizures (rare)"], col:"1A5276" },
  ];

  systems.forEach((sys, i) => {
    const col = i < 3 ? i : i-3;
    const row = i < 3 ? 0 : 1;
    const x = i<3 ? 0.35 + i*3.2 : 0.35 + col*4.8;
    const y = row===0 ? 1.42 : 3.42;
    const w = i<3 ? 3.0 : 4.5;

    s.addShape(pres.ShapeType.rect, { x, y, w, h:1.85, fill:{ color:"FFFFFF" }, line:{color:sys.col,pt:2} });
    accent(s, x, y, w, 0.42, sys.col);
    s.addText(sys.sys, { x, y:y+0.04, w, h:0.38, fontSize:11.5, bold:true, color:C.white, align:"center", margin:0 });
    const lines = sys.items.map((it,si) => ({
      text:it, options:{ bullet:{indent:0.2}, fontSize:11, color:C.textDark, breakLine:si<sys.items.length-1 }
    }));
    s.addText(lines, { x:x+0.1, y:y+0.46, w:w-0.2, h:1.32, valign:"top" });
  });

  s.addText("⚠  Absence of skin signs does NOT exclude anaphylaxis (occurs in ~10–20% of cases)", {
    x:0.35, y:5.23, w:9.3, h:0.36, fontSize:11, color:C.crimson, bold:true, italic:true
  });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 7 — RISK STRATIFICATION & GRADING
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionHeader(s, "RISK STRATIFICATION", C.navy);
  slideTitle(s, "Severity Grading (Ring & Messmer) & Risk Factors", C.navy);

  const grades = [
    { g:"Grade I", feat:"Skin / mucosa only (urticaria, angioedema, flushing)", bg:"FEF9E7", border:C.amber },
    { g:"Grade II", feat:"Moderate: multi-organ (skin + mild respiratory / GI / CV)", bg:"FDEBD0", border:"E67E22" },
    { g:"Grade III", feat:"Severe: bronchospasm, laryngeal edema, or significant hypotension", bg:"FDEDEC", border:C.crimson },
    { g:"Grade IV", feat:"Cardiac/respiratory arrest", bg:"F5B7B1", border:"922B21" },
  ];

  grades.forEach((gr,i) => {
    const y = 1.44 + i*0.88;
    s.addShape(pres.ShapeType.rect, { x:0.35, y, w:9.3, h:0.76, fill:{ color:gr.bg }, line:{color:gr.border,pt:2} });
    s.addText(gr.g, { x:0.5, y:y+0.1, w:1.2, h:0.5, fontSize:12.5, bold:true, color:gr.border });
    s.addText(gr.feat, { x:1.8, y:y+0.1, w:7.7, h:0.5, fontSize:12, color:C.textDark, valign:"middle" });
  });

  s.addText("High-Risk Features (severity amplifiers):", { x:0.35, y:5.0, w:4.5, h:0.35, fontSize:12.5, bold:true, color:C.navy });
  const riskItems = ["Cardiovascular disease / asthma","Age extremes (infants, elderly)","Beta-blockers / ACE inhibitors","Mastocytosis / hereditary α-tryptasemia","Delayed epinephrine administration","Upright posture at reaction onset"];
  const riskLines = riskItems.map((it,si) => ({ text:it, options:{ bullet:{indent:0.2}, fontSize:11, color:C.textDark, breakLine:si<riskItems.length-1 } }));
  s.addText(riskLines, { x:0.35, y:5.35, w:4.5, h:1.9, valign:"top" });

  s.addShape(pres.ShapeType.rect, { x:5.0, y:5.0, w:4.7, h:0.38, fill:{ color:C.crimson }, line:{color:C.crimson,pt:0} });
  s.addText("2024 Guideline: Severe = respiratory failure OR cardiovascular collapse", { x:5.1, y:5.04, w:4.5, h:0.3, fontSize:10.5, color:C.white, italic:true });
  const addlItems = ["Prior anaphylaxis episode","NSAIDs concurrent use","Exercise as cofactor","Cognitive-impairing drugs (alcohol, sedatives)"];
  const addlLines = addlItems.map((it,si) => ({ text:it, options:{ bullet:{indent:0.2}, fontSize:11, color:C.textDark, breakLine:si<addlItems.length-1 } }));
  s.addText(addlLines, { x:5.0, y:5.42, w:4.7, h:1.5, valign:"top" });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 8 — DIFFERENTIAL DIAGNOSIS
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionHeader(s, "DIFFERENTIAL DIAGNOSIS", C.navy);
  slideTitle(s, "What Else Could It Be?", C.navy);

  const ddx = [
    { cat:"Vasovagal syncope", notes:"Bradycardia (not tachycardia); pallor > urticaria; no respiratory sx; resolves with supine position" },
    { cat:"Acute severe asthma", notes:"No skin/mucosal signs, no hypotension; slower onset; responds to bronchodilators alone" },
    { cat:"Angioedema (HAE / ACE-i induced)", notes:"No urticaria; no cardiovascular collapse; C4 low in HAE; history of ACE inhibitor use" },
    { cat:"Panic attack", notes:"No objective signs; BP may rise; no urticaria or angioedema; SpO₂ normal" },
    { cat:"Vocal cord dysfunction", notes:"Stridor on inspiration; laryngoscopy confirms; SpO₂ usually maintained" },
    { cat:"Scombroid fish poisoning", notes:"Flushing, headache; histamine ingestion from spoiled fish; tryptase normal" },
    { cat:"Carcinoid syndrome", notes:"Flushing, diarrhea, wheezing; chronic; elevated 5-HIAA; no IgE involvement" },
    { cat:"Distributive shock (sepsis, neurogenic)", notes:"Relevant history; no allergen exposure; no skin/mucosal changes" },
  ];

  const rows = ddx.map((row,i) => [
    { text: row.cat, options:{ bold:true, fontSize:11, color:C.white, fill:{ color: i%2===0 ? C.navy : C.cardBg } } },
    { text: row.notes, options:{ fontSize:11, color:C.white, fill:{ color: i%2===0 ? C.navy : C.cardBg } } },
  ]);

  s.addTable(rows, {
    x:0.35, y:1.42, w:9.3, colW:[2.2, 7.1], rowH:0.4,
    border:{ pt:1, color:"2A4A6A" },
  });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 9 — IMMEDIATE MANAGEMENT ALGORITHM
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  darkSlide(s);
  accent(s, 0, 0, 10, 0.55, C.crimson);
  s.addText("IMMEDIATE MANAGEMENT ALGORITHM", { x:0.3, y:0.08, w:9.4, h:0.38, fontSize:15, bold:true, color:C.white, margin:0 });
  slideTitle(s, "AAAAI/ACAAI 2024 — First 15 Minutes", C.white);

  const steps = [
    { n:"1", title:"CALL FOR HELP / ACTIVATE EMS", detail:"Position supine (or lateral if vomiting); elevate legs (unless dyspnea);\nRemove trigger if still present", col:C.crimson },
    { n:"2", title:"EPINEPHRINE 1:1000 — IM MID-OUTER THIGH", detail:"Adults: 0.3–0.5 mg (0.3–0.5 mL)  |  Children: 0.01 mg/kg (max 0.5 mg)\nRepeat every 5–15 min if inadequate response", col:"8B0000" },
    { n:"3", title:"AIRWAY + OXYGEN", detail:"High-flow O₂ (8–10 L/min)  |  Intubate early if stridor / worsening airway\nPrepare for surgical airway if intubation fails", col:C.teal },
    { n:"4", title:"IV ACCESS + FLUIDS", detail:"Large-bore IV  |  Aggressive IV crystalloid 1–2 L bolus for hypotension\nRepeat boluses if needed", col:"0E6655" },
    { n:"5", title:"MONITOR & REASSESS", detail:"Continuous cardiac + pulse oximetry monitoring\nRepeat epinephrine PRN; consider IV epinephrine infusion (0.05–0.2 mcg/kg/min) if refractory", col:C.amber },
  ];

  steps.forEach((st, i) => {
    const y = 1.44 + i*0.79;
    s.addShape(pres.ShapeType.rect, { x:0.35, y, w:0.5, h:0.65, fill:{ color:st.col }, line:{color:st.col,pt:0} });
    s.addText(st.n, { x:0.35, y, w:0.5, h:0.65, fontSize:18, bold:true, color:C.white, align:"center", valign:"middle" });
    s.addShape(pres.ShapeType.rect, { x:0.92, y, w:8.73, h:0.65, fill:{ color:C.cardBg }, line:{color:"2A4A6A",pt:1} });
    s.addText(st.title, { x:1.05, y:y+0.04, w:8.5, h:0.28, fontSize:12.5, bold:true, color:C.amber, margin:0 });
    s.addText(st.detail, { x:1.05, y:y+0.32, w:8.5, h:0.3, fontSize:10.5, color:C.silver, margin:0 });
  });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 10 — EPINEPHRINE (FIRST LINE)
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionHeader(s, "PHARMACOTHERAPY", C.crimson);
  slideTitle(s, "Epinephrine — Undisputed First-Line Agent", C.navy);

  // why epi box
  s.addShape(pres.ShapeType.rect, { x:0.35, y:1.42, w:9.3, h:0.7, fill:{ color:C.crimson }, line:{color:C.crimson,pt:0} });
  s.addText("Why Epinephrine? — α₁: vasoconstriction ↑BP  |  β₁: ↑HR & inotropy  |  β₂: bronchodilation  |  ↓ mast cell mediator release", {
    x:0.5, y:1.5, w:9.0, h:0.54, fontSize:12, bold:true, color:C.white
  });

  const dosingRows = [
    ["Route", "IM (mid-outer thigh)", "IV infusion (refractory)", "Subcutaneous", "Intranasal (neffy®, FDA 2023)"],
    ["Adults", "0.3–0.5 mg (1:1000)", "0.05–0.2 mcg/kg/min", "Less preferred — slower absorption", "2 mg per nostril (≥30 kg)"],
    ["Children", "0.01 mg/kg, max 0.5 mg", "0.01–0.1 mcg/kg/min", "Not recommended acutely", "1 mg if 15–<30 kg (FDA 2025)"],
    ["Repeat", "Every 5–15 min PRN", "Titrate to response", "—", "May repeat once in 10 min"],
  ];

  const tableRows = dosingRows.map((row, ri) => row.map((cell, ci) => ({
    text: cell,
    options: { bold: ri===0 || ci===0, fontSize:10.5, color:C.white, fill:{ color: ri===0 ? C.navy : ci===0 ? C.cardBg : "1C3248" } }
  })));

  s.addTable(tableRows, { x:0.35, y:2.18, w:9.3, colW:[1.4,2.5,2.1,1.9,1.4], rowH:0.52, border:{pt:1,color:"2A4A6A"} });

  s.addText("Common Myths vs. 2024 Evidence", { x:0.35, y:4.5, w:9.3, h:0.35, fontSize:13, bold:true, color:C.navy });
  const myths = [
    "❌ 'Try antihistamine first' → 2024 guidelines: epinephrine is first AND only essential acute medication",
    "❌ 'Subcutaneous epi is equivalent' → IM mid-outer thigh gives faster, higher peak serum levels",
    "❌ 'Mild reactions don't need epi' → severity can escalate unpredictably; treat early",
    "✅ neffy® (intranasal epinephrine) FDA-approved 2023 (adults/children ≥30 kg); pediatric 15–<30 kg dose added 2025",
  ];
  const mythLines = myths.map((m,mi) => ({ text:m, options:{ bullet:false, fontSize:11, color:C.textDark, breakLine:mi<myths.length-1 } }));
  s.addText(mythLines, { x:0.35, y:4.9, w:9.3, h:1.5, valign:"top", margin:4 });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 11 — ADJUNCT THERAPIES
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionHeader(s, "PHARMACOTHERAPY — ADJUNCTS", C.teal);
  slideTitle(s, "What About Antihistamines & Steroids? (2024 Update)", C.navy);

  // big warning
  s.addShape(pres.ShapeType.rect, { x:0.35, y:1.42, w:9.3, h:0.62, fill:{ color:"FFF3CD" }, line:{color:C.amber,pt:2} });
  s.addText("⚠  2024 Practice Parameter: Antihistamines & corticosteroids are ADJUNCT therapies only — they do NOT prevent or abort anaphylaxis progression and should NEVER delay epinephrine.", {
    x:0.55, y:1.5, w:8.9, h:0.5, fontSize:11.5, bold:true, color:"7B4F00"
  });

  const drugs = [
    {
      name:"H1 Antihistamines\n(e.g., diphenhydramine, cetirizine)",
      role:"Relieve cutaneous symptoms (urticaria, pruritus)\nNo effect on blood pressure or bronchospasm",
      dose:"Diphenhydramine: 25–50 mg IV/IM/PO\nCetirizine 10 mg PO (less sedating — preferred in 2024 guidance)",
      caveat:"Sedating antihistamines may mask progression. Non-sedating preferred in ambulatory follow-up.",
      col:C.teal,
    },
    {
      name:"H2 Antihistamines\n(ranitidine → now famotidine 20 mg IV)",
      role:"Additive benefit for skin symptoms; mild BP effect",
      dose:"Famotidine 20 mg IV — may be used adjunctively",
      caveat:"Evidence limited; use as adjunct only",
      col:"117A65",
    },
    {
      name:"Corticosteroids\n(methylprednisolone, hydrocortisone, prednisone)",
      role:"Historically used to prevent biphasic anaphylaxis\n2024: NO convincing evidence they prevent biphasic reactions",
      dose:"Methylprednisolone 1–2 mg/kg IV (or prednisone 1 mg/kg PO)\nDuration 1–3 days if given",
      caveat:"2024 guidelines: Routine steroids are being de-emphasized. Many EDs removing them from anaphylaxis order sets.",
      col:C.crimson,
    },
  ];

  drugs.forEach((dr, i) => {
    const y = 2.14 + i*1.08;
    s.addShape(pres.ShapeType.rect, { x:0.35, y, w:9.3, h:0.98, fill:{ color:"FFFFFF" }, line:{color:dr.col,pt:2} });
    accent(s, 0.35, y, 2.15, 0.36, dr.col);
    s.addText(dr.name, { x:0.45, y:y+0.03, w:2.0, h:0.3, fontSize:10, bold:true, color:C.white, margin:0 });
    s.addText("Role: " + dr.role, { x:2.62, y:y+0.03, w:3.55, h:0.44, fontSize:10, color:C.textDark });
    s.addText("Dose: " + dr.dose, { x:6.28, y:y+0.03, w:3.28, h:0.44, fontSize:10, color:C.textDark });
    s.addText("⚑ " + dr.caveat, { x:0.45, y:y+0.52, w:9.1, h:0.4, fontSize:9.5, color:"555555", italic:true });
  });

  // bronchodilators
  s.addShape(pres.ShapeType.rect, { x:0.35, y:5.3, w:9.3, h:0.38, fill:{ color:C.navy }, line:{color:C.navy,pt:0} });
  s.addText("Bronchodilators (salbutamol / albuterol nebulization): for bronchospasm AFTER epinephrine, not as substitute", {
    x:0.5, y:5.34, w:9.0, h:0.3, fontSize:10.5, color:C.amber
  });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 12 — REFRACTORY ANAPHYLAXIS
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  darkSlide(s);
  accent(s, 0, 0, 10, 0.55, C.crimson);
  s.addText("REFRACTORY ANAPHYLAXIS", { x:0.3, y:0.08, w:9.4, h:0.38, fontSize:15, bold:true, color:C.white, margin:0 });
  slideTitle(s, "When Standard Therapy Fails", C.white);

  const agents = [
    { drug:"IV Epinephrine Infusion", detail:"0.05–0.2 mcg/kg/min; titrate to MAP >65; requires cardiac monitoring", ind:"Multiple epi doses without improvement" },
    { drug:"Glucagon", detail:"1–2 mg IV/IM, repeat q5 min or infusion 5–15 mcg/min", ind:"Beta-blocker–induced refractoriness; blocks epinephrine effect" },
    { drug:"Vasopressors (norepinephrine, vasopressin)", detail:"Norepinephrine 0.1–1 mcg/kg/min; Vasopressin 0.03 units/min", ind:"Refractory distributive shock despite fluid resuscitation" },
    { drug:"Atropine", detail:"0.5 mg IV repeated PRN (max 3 mg)", ind:"Bradycardia complicating anaphylaxis" },
    { drug:"Methylene Blue (emerging)", detail:"1–2 mg/kg IV — inhibits NO synthase, for severe refractory vasodilation", ind:"Vasoplegic state unresponsive to catecholamines" },
    { drug:"ECMO / Cardiac Support", detail:"In extremis: cardiogenic shock or cardiac arrest not responding to resuscitation", ind:"Last-resort measure in specialized centers" },
  ];

  const rows = agents.map((ag, i) => [
    { text:ag.drug, options:{ bold:true, fontSize:10.5, color:C.white, fill:{ color: i%2===0 ? C.cardBg : "142535" } } },
    { text:ag.detail, options:{ fontSize:10, color:C.silver, fill:{ color: i%2===0 ? C.cardBg : "142535" } } },
    { text:ag.ind, options:{ fontSize:10, italic:true, color:C.amber, fill:{ color: i%2===0 ? C.cardBg : "142535" } } },
  ]);

  s.addTable(
    [[
      { text:"Agent", options:{ bold:true, fontSize:11, color:C.white, fill:{ color:C.crimson } } },
      { text:"Dose / Administration", options:{ bold:true, fontSize:11, color:C.white, fill:{ color:C.crimson } } },
      { text:"Indication / Context", options:{ bold:true, fontSize:11, color:C.white, fill:{ color:C.crimson } } },
    ], ...rows],
    { x:0.35, y:1.44, w:9.3, colW:[2.2,4.2,2.9], rowH:0.55, border:{pt:1,color:"2A4A6A"} }
  );
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 13 — BIPHASIC ANAPHYLAXIS
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionHeader(s, "BIPHASIC ANAPHYLAXIS & OBSERVATION", C.navy);
  slideTitle(s, "When Symptoms Return After Resolution", C.navy);

  // stat box
  s.addShape(pres.ShapeType.rect, { x:0.35, y:1.42, w:4.4, h:1.8, fill:{ color:C.navy }, line:{color:C.navy,pt:0} });
  s.addText("Biphasic Anaphylaxis", { x:0.5, y:1.52, w:4.1, h:0.36, fontSize:14, bold:true, color:C.amber });
  s.addText([
    { text:"Incidence: ", options:{ bold:true, color:C.white } },
    { text:"~1–20% of cases\n", options:{ color:C.silver } },
    { text:"Onset: ", options:{ bold:true, color:C.white } },
    { text:"1 to 72 hours after initial reaction\n", options:{ color:C.silver } },
    { text:"Peak risk: ", options:{ bold:true, color:C.white } },
    { text:"8–12 hours post-reaction\n", options:{ color:C.silver } },
    { text:"Severity: ", options:{ bold:true, color:C.white } },
    { text:"Can be equal to or worse than initial", options:{ color:C.silver } },
  ], { x:0.5, y:1.94, w:4.1, h:1.22, fontSize:11.5 });

  s.addShape(pres.ShapeType.rect, { x:5.0, y:1.42, w:4.65, h:1.8, fill:{ color:"FFF3CD" }, line:{color:C.amber,pt:2} });
  s.addText("Risk Factors for Biphasic Reaction:", { x:5.15, y:1.52, w:4.35, h:0.36, fontSize:13, bold:true, color:C.textDark });
  const biphasicRF = ["Severe initial reaction","Required >1 dose of epinephrine","Unknown or ongoing allergen exposure","Delayed initial epinephrine","Protracted initial reaction"];
  const bpLines = biphasicRF.map((it,si) => ({ text:it, options:{ bullet:{indent:0.2}, fontSize:11, color:C.textDark, breakLine:si<biphasicRF.length-1 } }));
  s.addText(bpLines, { x:5.15, y:1.94, w:4.35, h:1.22, valign:"top" });

  s.addText("Observation Period — 2024 Recommendations", { x:0.35, y:3.35, w:9.3, h:0.38, fontSize:14, bold:true, color:C.navy });

  const obs = [
    { time:"≥1 hour", desc:"Mild reaction, rapid COMPLETE response to single epi, no high-risk features, reliable EAI access", col:C.teal },
    { time:"4–6 hours", desc:"Moderate reaction OR required >1 epi dose OR presence of any risk factor for severity", col:C.amber },
    { time:"≥6–24 hours", desc:"Severe reaction (Grade III–IV), refractory, uncertain trigger or access issues", col:C.crimson },
  ];
  obs.forEach((ob, i) => {
    const y = 3.8 + i*0.56;
    accent(s, 0.35, y, 1.35, 0.47, ob.col);
    s.addText(ob.time, { x:0.35, y:y+0.05, w:1.35, h:0.38, fontSize:13, bold:true, color:C.white, align:"center", margin:0 });
    s.addShape(pres.ShapeType.rect, { x:1.76, y, w:7.89, h:0.47, fill:{ color:"FFFFFF" }, line:{color:ob.col,pt:1} });
    s.addText(ob.desc, { x:1.9, y:y+0.06, w:7.6, h:0.38, fontSize:11, color:C.textDark, valign:"middle" });
  });

  s.addShape(pres.ShapeType.rect, { x:0.35, y:5.5, w:9.3, h:0.3, fill:{ color:C.navy }, line:{color:C.navy,pt:0} });
  s.addText("2024 Update: Steroids do NOT reliably prevent biphasic reactions — observation period is the key safeguard", {
    x:0.5, y:5.53, w:9.0, h:0.24, fontSize:10, color:C.amber, italic:true
  });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 14 — SPECIAL POPULATIONS
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionHeader(s, "SPECIAL POPULATIONS", C.teal);
  slideTitle(s, "Infants, Pregnancy, Beta-Blocker Users, Mastocytosis", C.navy);

  const pops = [
    {
      pop:"Infants & Toddlers",
      icon:"👶",
      pts:["Diagnosis challenging — no age-specific criteria; use standard WAO/NIAID criteria","Key signs: crying/irritability, sudden pallor, limpness, drooling, stridor","EpiPen Jr (150 mcg) for 7.5–20 kg; neffy not yet approved <15 kg","2024 guideline: Discuss EAI prescription at every allergist visit"],
      col:C.teal,
    },
    {
      pop:"Pregnancy",
      icon:"🤱",
      pts:["Epinephrine is SAFE and MANDATORY — do not withhold","Uterine artery vasoconstriction (maternal benefit outweighs fetal risk)","Position in left lateral decubitus if >20 weeks (avoid aortocaval compression)","Fetal monitoring in all cases of maternal anaphylaxis"],
      col:"7D3C98",
    },
    {
      pop:"Beta-Blocker / ACE-i Users",
      icon:"💊",
      pts:["Beta-blockers blunt epinephrine response → more severe, prolonged reaction","ACE inhibitors impair bradykinin breakdown → worsen angioedema","Use glucagon 1–2 mg IV if epi inadequate","Higher-dose epinephrine may be needed; avoid EAI dose capping"],
      col:C.crimson,
    },
    {
      pop:"Mastocytosis / Hereditary α-Tryptasemia",
      icon:"🔬",
      pts:["Elevated baseline tryptase (>11.4 ng/mL) — key marker","Idiopathic anaphylaxis and insect-sting reactions most common triggers","Anti-IgE therapy (omalizumab) emerging for recurrent anaphylaxis","Check baseline tryptase in all recurrent idiopathic anaphylaxis cases"],
      col:C.amber,
    },
  ];

  pops.forEach((pop, i) => {
    const x = i < 2 ? 0.35 : 5.1;
    const y = i % 2 === 0 ? 1.42 : 3.52;
    s.addShape(pres.ShapeType.rect, { x, y, w:4.55, h:1.92, fill:{ color:"FFFFFF" }, line:{color:pop.col,pt:2} });
    accent(s, x, y, 4.55, 0.42, pop.col);
    s.addText(pop.pop, { x:x+0.08, y:y+0.06, w:4.3, h:0.32, fontSize:12, bold:true, color:C.white });
    const lines = pop.pts.map((pt,pi) => ({ text:pt, options:{ bullet:{indent:0.2}, fontSize:10.5, color:C.textDark, breakLine:pi<pop.pts.length-1 } }));
    s.addText(lines, { x:x+0.1, y:y+0.47, w:4.3, h:1.4, valign:"top", margin:2 });
  });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 15 — TRYPTASE & INVESTIGATIONS
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionHeader(s, "INVESTIGATIONS", C.navy);
  slideTitle(s, "Serum Tryptase & Diagnostic Workup", C.navy);

  s.addText("Anaphylaxis is a CLINICAL diagnosis — no test is required before treatment", {
    x:0.35, y:1.42, w:9.3, h:0.42, fontSize:13, bold:true, color:C.crimson, italic:true
  });

  const invs = [
    { test:"Serum Tryptase (Total)", timing:"ACUTE: 1–2 h post-reaction\nBASELINE: ≥24 h later", value:">2 + (1.2 × baseline) = positive\nBaseline >11.4 ng/mL → possible mastocytosis", use:"Confirms mast cell activation; medicolegal; prognostication" },
    { test:"CBC / Metabolic Panel", timing:"At presentation if severe", value:"Haemoconcentration, lactic acidosis, eosinophilia (in chronic)", use:"Assess severity, complications (AKI, DIC)" },
    { test:"Specific IgE (RAST) / Skin Prick Tests", timing:"4–6 weeks post-reaction", value:"Identifies triggering allergen", use:"Guides avoidance counseling and immunotherapy eligibility" },
    { test:"Serum Histamine", timing:"Within 30–60 min of reaction", value:"Very short half-life — practically less useful", use:"Research; rarely practical in clinical setting" },
    { test:"Urinary Histamine Metabolites", timing:"2–24 h post-reaction", value:"N-methylhistamine in 24-h urine", use:"Alternative when blood sample missed" },
  ];

  const rows = invs.map((inv, i) => [
    { text:inv.test, options:{ bold:true, fontSize:10.5, color:C.white, fill:{ color: i%2===0 ? C.navy : C.cardBg } } },
    { text:inv.timing, options:{ fontSize:10, color:C.silver, fill:{ color: i%2===0 ? C.navy : C.cardBg } } },
    { text:inv.value, options:{ fontSize:10, color:C.amber, fill:{ color: i%2===0 ? C.navy : C.cardBg } } },
    { text:inv.use, options:{ fontSize:10, color:C.silver, fill:{ color: i%2===0 ? C.navy : C.cardBg } } },
  ]);

  s.addTable(
    [[
      { text:"Test", options:{ bold:true, fontSize:11, color:C.white, fill:{ color:C.teal } } },
      { text:"Timing", options:{ bold:true, fontSize:11, color:C.white, fill:{ color:C.teal } } },
      { text:"Interpretation", options:{ bold:true, fontSize:11, color:C.white, fill:{ color:C.teal } } },
      { text:"Clinical Use", options:{ bold:true, fontSize:11, color:C.white, fill:{ color:C.teal } } },
    ], ...rows],
    { x:0.35, y:1.94, w:9.3, colW:[1.9,1.85,2.75,2.8], rowH:0.56, border:{pt:1,color:"2A4A6A"} }
  );

  s.addShape(pres.ShapeType.rect, { x:0.35, y:5.2, w:9.3, h:0.4, fill:{ color:"E8F8F5" }, line:{color:C.teal,pt:1} });
  s.addText("💡 2024 Recommendation: Measure tryptase in ALL ED-attended anaphylaxis cases; use formula (2 + 1.2×baseline) for diagnosis confirmation", {
    x:0.5, y:5.24, w:9.0, h:0.32, fontSize:10.5, color:C.teal
  });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 16 — DISCHARGE & EAI
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionHeader(s, "DISCHARGE PLANNING & SELF-MANAGEMENT", C.teal);
  slideTitle(s, "Epinephrine Auto-Injectors & Patient Education", C.navy);

  // EAI prescribing
  s.addShape(pres.ShapeType.rect, { x:0.35, y:1.42, w:9.3, h:0.38, fill:{ color:C.teal }, line:{color:C.teal,pt:0} });
  s.addText("ALL patients who experienced anaphylaxis should be prescribed ≥2 epinephrine auto-injectors at discharge", {
    x:0.5, y:1.46, w:9.0, h:0.3, fontSize:12, bold:true, color:C.white
  });

  const eaiData = [
    { brand:"EpiPen Jr® / Auvi-Q 0.1 mg", weight:"7.5–15 kg", dose:"150 mcg", note:"Toddler / small child" },
    { brand:"EpiPen® / Auvi-Q 0.15 mg", weight:"15–30 kg", dose:"150–300 mcg", note:"Children (standard)" },
    { brand:"EpiPen® / neffy® 2 mg intranasal", weight:"≥30 kg / adult", dose:"300–500 mcg", note:"Most adults; neffy nasal spray 2 mg" },
    { brand:"neffy® 1 mg intranasal", weight:"15–<30 kg", dose:"1 mg per nostril", note:"FDA-approved March 2025 for pediatric" },
  ];
  const eaiRows = eaiData.map((row, i) => [
    { text:row.brand, options:{ bold:true, fontSize:11, color:C.white, fill:{ color:i%2===0?C.navy:C.cardBg } } },
    { text:row.weight, options:{ fontSize:11, color:C.white, fill:{ color:i%2===0?C.navy:C.cardBg }, align:"center" } },
    { text:row.dose, options:{ bold:true, fontSize:11, color:C.amber, fill:{ color:i%2===0?C.navy:C.cardBg }, align:"center" } },
    { text:row.note, options:{ fontSize:11, color:C.silver, fill:{ color:i%2===0?C.navy:C.cardBg } } },
  ]);
  s.addTable(
    [[{text:"Device",options:{bold:true,fontSize:11,color:C.white,fill:{color:C.crimson}}},{text:"Weight",options:{bold:true,fontSize:11,color:C.white,fill:{color:C.crimson}}},{text:"Dose",options:{bold:true,fontSize:11,color:C.white,fill:{color:C.crimson}}},{text:"Notes",options:{bold:true,fontSize:11,color:C.white,fill:{color:C.crimson}}}}, ...eaiRows],
    { x:0.35, y:1.88, w:9.3, colW:[3.0,1.7,1.8,2.8], rowH:0.44, border:{pt:1,color:"2A4A6A"} }
  );

  s.addText("Discharge Checklist (2024 Guidelines)", { x:0.35, y:4.05, w:4.5, h:0.35, fontSize:13, bold:true, color:C.navy });
  const checklist = ["Prescribe ≥2 EAIs (check for concurrent prescriptions in household)","Written anaphylaxis action plan","Instruction on EAI technique (demonstrate)","Allergen avoidance counseling (trigger-specific)","Medical alert bracelet / jewellery recommendation","Referral to allergist within 1 month","Discuss EMS call: NOT mandatory if complete response to epi + access to 2nd dose","Schedule follow-up serum tryptase (baseline if not done)"];
  const checkLines = checklist.map((it,si) => ({ text:"☐  "+it, options:{ fontSize:11, color:C.textDark, breakLine:si<checklist.length-1 } }));
  s.addText(checkLines, { x:0.35, y:4.44, w:4.55, h:3.0, valign:"top", margin:2 });

  // EMS update box
  s.addShape(pres.ShapeType.rect, { x:5.1, y:4.05, w:4.55, h:1.62, fill:{ color:"E8F8F5" }, line:{color:C.teal,pt:2} });
  s.addText("2024 Update: EMS Activation", { x:5.25, y:4.12, w:4.2, h:0.36, fontSize:13, bold:true, color:C.teal });
  s.addText("EMS activation after EAI use MAY NOT be required if:\n• Prompt, complete, durable symptom resolution\n• Access to ≥2 additional EAIs\n• Reliable patient/caregiver\n\nEMS is still required for:\n• Severe anaphylaxis (respiratory failure, CV collapse)\n• Incomplete or worsening response\n• Return of symptoms", {
    x:5.25, y:4.5, w:4.3, h:2.0, fontSize:10.5, color:C.textDark
  });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 17 — LONG-TERM PREVENTION & IMMUNOTHERAPY
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionHeader(s, "LONG-TERM PREVENTION", C.teal);
  slideTitle(s, "Allergen Immunotherapy, Omalizumab & Risk Reduction", C.navy);

  const strategies = [
    {
      title:"Venom Immunotherapy (VIT)",
      detail:"Highly effective (97–98%) for Hymenoptera venom allergy\nRecommended for all adults with systemic venom reactions\n3–5 year course; consider lifelong if severe reaction or mastocytosis",
      evidence:"Strong — Grade A recommendation",
      col:C.teal,
    },
    {
      title:"Drug Desensitization",
      detail:"For patients requiring a causative drug (e.g. aspirin, platinum chemotherapy)\nRapid graded-dose protocol under supervised setting\nConfers temporary tolerance only — must repeat",
      evidence:"Moderate — case series, expert consensus",
      col:C.navy,
    },
    {
      title:"Oral Immunotherapy (OIT) — Food",
      detail:"Peanut OIT (Palforzia) FDA-approved for ages 4–17\nReduces threshold dose significantly\n2024 EAACI food allergy guidelines: OIT preferred over avoidance alone",
      evidence:"Strong for peanut — Grade B for others",
      col:"1A5276",
    },
    {
      title:"Omalizumab (anti-IgE)",
      detail:"Reduces anaphylaxis risk in food-triggered disease\nApproved 2024 by FDA for IgE-mediated food allergy (6+ years)\nAlso used in mastocytosis and chronic spontaneous urticaria",
      evidence:"Strong for food allergy and chronic urticaria",
      col:C.crimson,
    },
  ];

  strategies.forEach((str, i) => {
    const x = i < 2 ? 0.35 : 5.1;
    const y = i%2===0 ? 1.42 : 3.3;
    s.addShape(pres.ShapeType.rect, { x, y, w:4.55, h:1.74, fill:{ color:"FFFFFF" }, line:{color:str.col,pt:2} });
    accent(s, x, y, 4.55, 0.4, str.col);
    s.addText(str.title, { x:x+0.1, y:y+0.05, w:4.3, h:0.32, fontSize:12, bold:true, color:C.white });
    s.addText(str.detail, { x:x+0.1, y:y+0.44, w:4.3, h:0.9, fontSize:10.5, color:C.textDark, valign:"top" });
    s.addShape(pres.ShapeType.rect, { x, y:y+1.36, w:4.55, h:0.38, fill:{ color:str.col+"33" }, line:{color:str.col,pt:0} });
    s.addText("Evidence: " + str.evidence, { x:x+0.1, y:y+1.4, w:4.3, h:0.3, fontSize:10, italic:true, color:str.col });
  });

  s.addShape(pres.ShapeType.rect, { x:0.35, y:5.12, w:9.3, h:0.42, fill:{ color:"FFF9E6" }, line:{color:C.amber,pt:1} });
  s.addText("Cofactor management: advise NSAID avoidance before known allergen exposure; exercise precautions in food-dependent EIA", {
    x:0.5, y:5.16, w:9.0, h:0.34, fontSize:11, color:C.textDark
  });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 18 — PERIOPERATIVE ANAPHYLAXIS
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionHeader(s, "PERIOPERATIVE ANAPHYLAXIS", C.crimson);
  slideTitle(s, "Intraoperative Recognition & Management", C.navy);

  s.addText("Incidence: 1 in 2,000–10,000 anesthetics | Mortality: ~3–9%", {
    x:0.35, y:1.44, w:9.3, h:0.38, fontSize:13, bold:true, color:C.crimson
  });

  const triggers = [
    ["Neuromuscular blocking agents (NMBAs)","Most common — rocuronium, succinylcholine","IgE-mediated or direct degranulation"],
    ["Antibiotics","Penicillins, cephalosporins, vancomycin","IgE-mediated or infusion-related"],
    ["Latex","Gloves, drapes — less common post-latex-free protocols","IgE-mediated"],
    ["Chlorhexidine","Skin prep, IV flush","IgE-mediated; often delayed presentation"],
    ["Dyes (isosulfan blue, patent blue)","Sentinel node biopsy","IgE-mediated; cutaneous signs may be hidden"],
    ["Colloids / gelatin","Plasma expanders","Non-IgE complement activation"],
  ];

  const trigRows = triggers.map((row, i) => row.map((cell, ci) => ({
    text:cell,
    options:{ bold:ci===0, fontSize:10.5, color:C.white, fill:{ color:i%2===0?C.cardBg:C.navy } }
  })));
  s.addTable(
    [[{text:"Trigger",options:{bold:true,fontSize:11,color:C.white,fill:{color:C.crimson}}},{text:"Notes",options:{bold:true,fontSize:11,color:C.white,fill:{color:C.crimson}}},{text:"Mechanism",options:{bold:true,fontSize:11,color:C.white,fill:{color:C.crimson}}}}, ...trigRows],
    { x:0.35, y:1.9, w:9.3, colW:[2.5,3.8,3.0], rowH:0.44, border:{pt:1,color:"2A4A6A"} }
  );

  s.addShape(pres.ShapeType.rect, { x:0.35, y:4.98, w:9.3, h:0.62, fill:{ color:"FFF3CD" }, line:{color:C.amber,pt:2} });
  s.addText("Intraoperative signs may be masked by drapes: monitor for unexplained tachycardia, bronchospasm, hypotension, capnography changes. \nTreat with IM/IV epinephrine immediately; stop surgery if safe; call allergist within 24 h for full workup.", {
    x:0.5, y:5.03, w:9.0, h:0.5, fontSize:10.5, color:"7B4F00"
  });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 19 — 2024 GUIDELINE KEY UPDATES
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  darkSlide(s);
  accent(s, 0, 0, 10, 0.55, C.amber);
  s.addText("KEY 2024 GUIDELINE UPDATES", { x:0.3, y:0.08, w:9.4, h:0.38, fontSize:16, bold:true, color:C.navy, margin:0 });
  slideTitle(s, "AAAAI/ACAAI 2023 Practice Parameter (Annals 2024) — What Changed?", C.white);

  const updates = [
    {
      tag:"Epinephrine",
      text:"Epinephrine at first concern for systemic allergic reaction — even if formal criteria not yet met. No more 'wait and see' approach.",
      col:C.crimson,
    },
    {
      tag:"Steroids",
      text:"Corticosteroids de-emphasized: no reliable evidence they prevent biphasic reactions. Many centres removing them from standard anaphylaxis pathways.",
      col:C.amber,
    },
    {
      tag:"Antihistamines",
      text:"Non-sedating antihistamines preferred over diphenhydramine. Sedating antihistamines may mask symptom progression during active reaction.",
      col:C.teal,
    },
    {
      tag:"Observation",
      text:"Individualised observation: 1 h for mild complete responders; ≥6 h for severe/refractory; steroid-based biphasic prevention abandoned.",
      col:"7D3C98",
    },
    {
      tag:"EMS After EAI",
      text:"EMS NOT mandatory if: complete + durable symptom resolution after EAI AND patient has access to ≥2 additional EAIs. Still required for severe reactions.",
      col:"1A5276",
    },
    {
      tag:"Infants",
      text:"Standard WAO/NIAID criteria apply to infants/toddlers — no separate criteria. Skin signs may be subtle; stridor and limpness are key red flags.",
      col:"117A65",
    },
    {
      tag:"Tryptase Formula",
      text:"Diagnosis supported by: serum tryptase > (2 + 1.2 × baseline). Baseline tryptase >11.4 ng/mL warrants workup for mastocytosis/hereditary α-tryptasemia.",
      col:"884EA0",
    },
    {
      tag:"neffy® (intranasal epi)",
      text:"FDA approved 2023 for adults/≥30 kg; pediatric dose 1 mg for 15–<30 kg approved March 2025. Addresses needle phobia barriers to epinephrine access.",
      col:C.crimson,
    },
  ];

  updates.forEach((upd, i) => {
    const x = i < 4 ? 0.35 : 5.1;
    const y = 1.44 + (i%4)*0.97;
    s.addShape(pres.ShapeType.rect, { x, y, w:4.55, h:0.87, fill:{ color:C.cardBg }, line:{color:upd.col,pt:2} });
    s.addShape(pres.ShapeType.rect, { x, y, w:1.2, h:0.38, fill:{ color:upd.col }, line:{color:upd.col,pt:0} });
    s.addText(upd.tag, { x, y:y+0.04, w:1.2, h:0.3, fontSize:10.5, bold:true, color:C.white, align:"center", margin:0 });
    s.addText(upd.text, { x:x+0.1, y:y+0.4, w:4.3, h:0.44, fontSize:10, color:C.silver, valign:"top" });
  });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 20 — RADIOCONTRAST MEDIA
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionHeader(s, "RADIOCONTRAST MEDIA REACTIONS", C.navy);
  slideTitle(s, "Management & Premedication — 2024 Update", C.navy);

  s.addShape(pres.ShapeType.rect, { x:0.35, y:1.42, w:9.3, h:0.46, fill:{ color:"E8F8F5" }, line:{color:C.teal,pt:2} });
  s.addText("ICM reactions are largely NON-IgE; prior seafood/iodine allergy does NOT increase risk — avoid this label", {
    x:0.5, y:1.47, w:9.0, h:0.36, fontSize:12, bold:true, color:C.teal
  });

  const cols = [
    {
      title:"Risk Factors for ICM Reaction",
      items:["Prior adverse reaction to ICM (strongest)","History of atopy, asthma","Certain medications: ACE inhibitors, β-blockers, proton pump inhibitors","Renal impairment (for delayed reactions)"],
      col:C.crimson
    },
    {
      title:"Premedication Protocol\n(CAR/CSACI 2025 Guidance)",
      items:["Prednisolone 50 mg PO at 13h, 7h, 1h before ICM","Diphenhydramine 50 mg PO/IM 1h before","Use LOW/ISO-osmolar contrast preferentially","2024 Update: Routine premedication questioned — evidence weak for low-osmolar agents; individualise risk-benefit"],
      col:C.teal
    },
    {
      title:"2024 Practical Note",
      items:["Do NOT delay emergent CT scanning to administer premedication","Switch to alternative imaging if non-emergent in high-risk patient","GBCA (MRI contrast): cross-reactivity with ICM = NONE","Report all reactions to pharmacovigilance"],
      col:C.amber
    }
  ];

  cols.forEach((col, i) => {
    const x = 0.35 + i*3.2;
    s.addShape(pres.ShapeType.rect, { x, y:2.0, w:3.0, h:3.35, fill:{ color:"FFFFFF" }, line:{color:col.col,pt:2} });
    accent(s, x, 2.0, 3.0, 0.42, col.col);
    s.addText(col.title, { x:x+0.05, y:2.04, w:2.9, h:0.38, fontSize:10.5, bold:true, color:C.white, align:"center", margin:0 });
    const lines = col.items.map((it,si) => ({ text:it, options:{ bullet:{indent:0.2}, fontSize:10.5, color:C.textDark, breakLine:si<col.items.length-1 } }));
    s.addText(lines, { x:x+0.1, y:2.46, w:2.8, h:2.82, valign:"top", margin:2 });
  });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 21 — SUMMARY QUICK REFERENCE
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  darkSlide(s);
  accent(s, 0, 0, 10, 0.55, C.crimson);
  s.addText("CLINICAL QUICK REFERENCE", { x:0.3, y:0.08, w:9.4, h:0.38, fontSize:16, bold:true, color:C.white, margin:0 });
  slideTitle(s, "Anaphylaxis Management at a Glance", C.white);

  const qref = [
    { label:"RECOGNIZE", val:"Skin/mucosa + respiratory OR hypotension ± GI within minutes of exposure", col:C.teal },
    { label:"CALL FOR HELP", val:"Activate EMS / crash team immediately", col:"117A65" },
    { label:"EPINEPHRINE", val:"IM 1:1000 — mid-outer thigh — 0.3–0.5 mg adult / 0.01 mg/kg child — FIRST", col:C.crimson },
    { label:"POSITION", val:"Supine + legs elevated; lateral if vomiting; left lateral if pregnant", col:C.amber },
    { label:"OXYGEN", val:"High-flow O₂ (8–10 L/min); intubate early for stridor", col:"1A5276" },
    { label:"IV FLUIDS", val:"1–2 L crystalloid bolus for hypotension; repeat PRN", col:"7D3C98" },
    { label:"REPEAT EPI", val:"Every 5–15 min if insufficient response; IV infusion if refractory", col:"8B0000" },
    { label:"OBSERVE", val:"≥1h mild | ≥4–6h moderate | ≥6–24h severe before discharge", col:C.navy+"AA" },
    { label:"DISCHARGE", val:"≥2 EAIs + action plan + allergist referral + tryptase baseline", col:"0A6251" },
  ];

  qref.forEach((item, i) => {
    const row = Math.floor(i/3);
    const col = i%3;
    const x = 0.35 + col*3.2;
    const y = 1.44 + row*1.3;
    s.addShape(pres.ShapeType.rect, { x, y, w:3.0, h:1.15, fill:{ color:C.cardBg }, line:{color:item.col,pt:2} });
    accent(s, x, y, 3.0, 0.38, item.col);
    s.addText(item.label, { x:x+0.06, y:y+0.05, w:2.88, h:0.28, fontSize:12, bold:true, color:C.white, align:"center", margin:0 });
    s.addText(item.val, { x:x+0.08, y:y+0.42, w:2.84, h:0.68, fontSize:10, color:C.silver, valign:"top" });
  });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 22 — REFERENCES
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  darkSlide(s);
  accent(s, 0, 0, 10, 0.55, C.navy);
  s.addText("REFERENCES & SOURCES", { x:0.3, y:0.08, w:9.4, h:0.38, fontSize:16, bold:true, color:C.white, margin:0 });

  const refs = [
    "1. Golden DBK, Wang J, Waserman S, et al. Anaphylaxis: A 2023 Practice Parameter Update. Ann Allergy Asthma Immunol. 2024;132(2):124-176.",
    "2. Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second Symposium on the Definition and Management of Anaphylaxis. J Allergy Clin Immunol. 2006;117(2):391-7.",
    "3. Simons FE, Ardusso LR, Bilò MB, et al. World Allergy Organization Anaphylaxis Guidelines: Summary. J Allergy Clin Immunol. 2011;127(3):587-93.",
    "4. Hewett Brumberg EK et al. 2024 AHA/ARC Guidelines for First Aid. Circulation. 2024 Dec;150(24). PMID 39540278.",
    "5. Byrne A et al. CAR/CSACI Practice Guidance for Contrast Media Hypersensitivity. Can Assoc Radiol J. 2025 Aug. PMID 39797723.",
    "6. Rosen's Emergency Medicine: Concepts & Clinical Practice, 10th Ed. Chapter 106: Anaphylaxis.",
    "7. Goldman-Cecil Medicine, International Edition, 2-Volume Set. Chapter 233: Anaphylaxis. Schwartz LB, Castells M.",
    "8. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. Chapter: Anaphylaxis.",
    "9. Miller's Anesthesia, 10th Ed. Chapter: Perioperative Anaphylaxis.",
    "10. Santos AF et al. EAACI Guidelines on Management of IgE-Mediated Food Allergy. Allergy. 2025;80(1). PMID 39473345.",
    "11. AAAAI/ACAAI Joint Task Force. 2020 Practice Parameter Update — Focused Questions on Epinephrine. Ann Allergy Asthma Immunol.",
    "12. ARS Pharmaceuticals. neffy® 1 mg (epinephrine nasal spray) FDA Approval for Pediatric Patients 15–<30 kg. March 2025.",
  ];

  const refLines = refs.map((r, ri) => ({ text:r, options:{ fontSize:10, color: ri%2===0 ? C.silver : C.white, breakLine: ri<refs.length-1 } }));
  s.addText(refLines, { x:0.4, y:0.66, w:9.2, h:4.8, valign:"top", margin:4, paraSpaceAfter:3 });

  // footer
  accent(s, 0, 5.35, 10, 0.28, C.crimson);
  s.addText("Prepared using AAAAI/ACAAI 2024 Practice Parameters · WAO Guidelines · Goldman-Cecil Medicine · Rosen's Emergency Medicine · July 2026", {
    x:0.3, y:5.38, w:9.4, h:0.22, fontSize:9, color:C.white, align:"center"
  });
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SAVE
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
pres.writeFile({ fileName: "/home/daytona/workspace/anaphylaxis-ppt/Anaphylaxis_Guidelines_2026.pptx" })
  .then(() => console.log("✅ PPT saved: Anaphylaxis_Guidelines_2026.pptx"))
  .catch(err => { console.error("❌ Error:", err); process.exit(1); });

~/anaphylaxis-ppt/build.js

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/anaphylaxis-ppt/build.js'

cd /home/daytona/workspace/anaphylaxis-ppt && node build.js 2>&1