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

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Point-of-Care Ultrasound (POCUS) in the ICU";
pres.author = "Critical Care Medicine";

// ─── COLOR PALETTE ────────────────────────────────────────────────────────────
const C = {
  navy:    "0A1A2F",   // dominant dark background
  teal:    "00B4C8",   // primary accent
  gold:    "F4A522",   // secondary accent / highlights
  white:   "F0F4F8",   // text on dark
  lightGray: "C8D6E5", // subtext
  darkPanel: "0F2540", // card / panel background
  midPanel:  "132D50", // slightly lighter panel
  orange:  "E87722",   // warning / key stat
  green:   "22C55E",   // positive finding
  red:     "EF4444",   // abnormal / alert
};

// ─── HELPER FUNCTIONS ─────────────────────────────────────────────────────────

function addBg(slide, color) {
  slide.addShape(pres.ShapeType.rect, {
    x: 0, y: 0, w: "100%", h: "100%",
    fill: { color: color || C.navy },
    line: { type: "none" },
  });
}

function titleSlide(title, subtitle, accent) {
  const slide = pres.addSlide();
  addBg(slide, C.navy);
  // Left accent bar
  slide.addShape(pres.ShapeType.rect, {
    x: 0, y: 0, w: 0.18, h: "100%",
    fill: { color: accent || C.teal },
    line: { type: "none" },
  });
  // Decorative circle background
  slide.addShape(pres.ShapeType.ellipse, {
    x: 7.5, y: -1.0, w: 4.5, h: 4.5,
    fill: { color: C.darkPanel },
    line: { type: "none" },
  });
  slide.addShape(pres.ShapeType.ellipse, {
    x: 8.2, y: 2.8, w: 3.0, h: 3.0,
    fill: { color: C.midPanel },
    line: { type: "none" },
  });
  slide.addText(title, {
    x: 0.55, y: 1.4, w: 7.5, h: 1.4,
    fontSize: 40, bold: true, color: C.white, fontFace: "Calibri",
    align: "left", valign: "middle", margin: 0,
  });
  if (subtitle) {
    slide.addText(subtitle, {
      x: 0.55, y: 3.0, w: 7.5, h: 0.7,
      fontSize: 20, bold: false, color: C.teal, fontFace: "Calibri",
      align: "left", margin: 0,
    });
  }
  // Bottom rule
  slide.addShape(pres.ShapeType.rect, {
    x: 0.55, y: 4.9, w: 9.0, h: 0.06,
    fill: { color: accent || C.teal },
    line: { type: "none" },
  });
  return slide;
}

function sectionDivider(label, subtitle) {
  const slide = pres.addSlide();
  addBg(slide, C.darkPanel);
  // Full-width color bar at top
  slide.addShape(pres.ShapeType.rect, {
    x: 0, y: 0, w: "100%", h: 0.22,
    fill: { color: C.teal },
    line: { type: "none" },
  });
  slide.addShape(pres.ShapeType.rect, {
    x: 0, y: 5.4, w: "100%", h: 0.225,
    fill: { color: C.teal },
    line: { type: "none" },
  });
  slide.addText("SECTION", {
    x: 0.5, y: 1.5, w: 9, h: 0.5,
    fontSize: 14, bold: true, color: C.teal, fontFace: "Calibri",
    charSpacing: 8, align: "center", margin: 0,
  });
  slide.addText(label, {
    x: 0.5, y: 2.0, w: 9, h: 1.3,
    fontSize: 36, bold: true, color: C.white, fontFace: "Calibri",
    align: "center", valign: "middle", margin: 0,
  });
  if (subtitle) {
    slide.addText(subtitle, {
      x: 1.0, y: 3.5, w: 8, h: 0.7,
      fontSize: 18, color: C.lightGray, fontFace: "Calibri",
      align: "center", margin: 0,
    });
  }
  return slide;
}

function contentSlide(title, bullets, accentColor) {
  const slide = pres.addSlide();
  addBg(slide, C.navy);
  // Left accent thin bar
  slide.addShape(pres.ShapeType.rect, {
    x: 0, y: 0, w: 0.12, h: "100%",
    fill: { color: accentColor || C.teal },
    line: { type: "none" },
  });
  // Title bar
  slide.addShape(pres.ShapeType.rect, {
    x: 0, y: 0, w: "100%", h: 0.85,
    fill: { color: C.darkPanel },
    line: { type: "none" },
  });
  slide.addText(title, {
    x: 0.3, y: 0.0, w: 9.4, h: 0.85,
    fontSize: 24, bold: true, color: C.white, fontFace: "Calibri",
    align: "left", valign: "middle", margin: [0, 0, 0, 10],
  });
  // Bullets
  const items = bullets.map((b, i) => {
    if (typeof b === "string") {
      return { text: b, options: { bullet: { type: "bullet", characterCode: "2022" }, color: C.white, fontSize: 17, fontFace: "Calibri", paraSpaceBefore: 6, breakLine: i < bullets.length - 1 } };
    } else {
      return { text: b.text, options: { bullet: { type: "bullet", characterCode: b.sub ? "25E6" : "2022" }, color: b.color || (b.sub ? C.lightGray : C.white), fontSize: b.sub ? 15 : 17, fontFace: "Calibri", paraSpaceBefore: b.sub ? 2 : 6, indentLevel: b.sub ? 1 : 0, breakLine: i < bullets.length - 1 } };
    }
  });
  slide.addText(items, {
    x: 0.3, y: 1.0, w: 9.4, h: 4.3,
    valign: "top", margin: [6, 10, 6, 10],
  });
  return slide;
}

function twoColumnSlide(title, leftHeader, leftBullets, rightHeader, rightBullets, accentLeft, accentRight) {
  const slide = pres.addSlide();
  addBg(slide, C.navy);
  slide.addShape(pres.ShapeType.rect, {
    x: 0, y: 0, w: "100%", h: 0.85,
    fill: { color: C.darkPanel },
    line: { type: "none" },
  });
  slide.addText(title, {
    x: 0.3, y: 0.0, w: 9.4, h: 0.85,
    fontSize: 24, bold: true, color: C.white, fontFace: "Calibri",
    align: "left", valign: "middle", margin: [0, 0, 0, 10],
  });
  // Left panel
  slide.addShape(pres.ShapeType.rect, {
    x: 0.2, y: 1.0, w: 4.55, h: 4.3,
    fill: { color: C.darkPanel },
    line: { color: accentLeft || C.teal, pt: 2, type: "solid" },
  });
  slide.addText(leftHeader, {
    x: 0.25, y: 1.05, w: 4.45, h: 0.45,
    fontSize: 15, bold: true, color: accentLeft || C.teal, fontFace: "Calibri",
    align: "center", valign: "middle",
  });
  const lItems = leftBullets.map((b, i) => ({
    text: typeof b === "string" ? b : b.text,
    options: { bullet: true, color: C.white, fontSize: 15, fontFace: "Calibri", paraSpaceBefore: 4, breakLine: i < leftBullets.length - 1 }
  }));
  slide.addText(lItems, {
    x: 0.3, y: 1.55, w: 4.35, h: 3.65, valign: "top", margin: [2, 6, 2, 6],
  });
  // Right panel
  slide.addShape(pres.ShapeType.rect, {
    x: 5.05, y: 1.0, w: 4.55, h: 4.3,
    fill: { color: C.darkPanel },
    line: { color: accentRight || C.gold, pt: 2, type: "solid" },
  });
  slide.addText(rightHeader, {
    x: 5.1, y: 1.05, w: 4.45, h: 0.45,
    fontSize: 15, bold: true, color: accentRight || C.gold, fontFace: "Calibri",
    align: "center", valign: "middle",
  });
  const rItems = rightBullets.map((b, i) => ({
    text: typeof b === "string" ? b : b.text,
    options: { bullet: true, color: C.white, fontSize: 15, fontFace: "Calibri", paraSpaceBefore: 4, breakLine: i < rightBullets.length - 1 }
  }));
  slide.addText(rItems, {
    x: 5.15, y: 1.55, w: 4.35, h: 3.65, valign: "top", margin: [2, 6, 2, 6],
  });
  return slide;
}

function imageSlide(title, imageData, caption, accentColor) {
  const slide = pres.addSlide();
  addBg(slide, C.navy);
  slide.addShape(pres.ShapeType.rect, {
    x: 0, y: 0, w: "100%", h: 0.75,
    fill: { color: C.darkPanel },
    line: { type: "none" },
  });
  slide.addText(title, {
    x: 0.3, y: 0.0, w: 9.4, h: 0.75,
    fontSize: 22, bold: true, color: C.white, fontFace: "Calibri",
    align: "left", valign: "middle", margin: [0, 0, 0, 8],
  });
  if (imageData && imageData !== "SKIP") {
    try {
      slide.addImage({ data: imageData, x: 1.8, y: 0.85, w: 6.4, h: 4.2 });
    } catch(e) {}
  }
  if (caption) {
    slide.addShape(pres.ShapeType.rect, {
      x: 0, y: 5.1, w: "100%", h: 0.52,
      fill: { color: C.darkPanel },
      line: { type: "none" },
    });
    slide.addShape(pres.ShapeType.rect, {
      x: 0, y: 5.1, w: 0.1, h: 0.52,
      fill: { color: accentColor || C.teal },
      line: { type: "none" },
    });
    slide.addText(caption, {
      x: 0.2, y: 5.1, w: 9.6, h: 0.52,
      fontSize: 13, italic: true, color: C.lightGray, fontFace: "Calibri",
      align: "left", valign: "middle",
    });
  }
  return slide;
}

function tableSlide(title, headers, rows, headerBg) {
  const slide = pres.addSlide();
  addBg(slide, C.navy);
  slide.addShape(pres.ShapeType.rect, {
    x: 0, y: 0, w: "100%", h: 0.85,
    fill: { color: C.darkPanel },
    line: { type: "none" },
  });
  slide.addText(title, {
    x: 0.3, y: 0.0, w: 9.4, h: 0.85,
    fontSize: 24, bold: true, color: C.white, fontFace: "Calibri",
    align: "left", valign: "middle", margin: [0, 0, 0, 10],
  });
  const tableRows = [];
  // Header row
  tableRows.push(headers.map(h => ({
    text: h,
    options: { bold: true, color: C.white, fontSize: 13, fill: { color: headerBg || C.teal }, align: "center", valign: "middle" }
  })));
  rows.forEach((row, ri) => {
    tableRows.push(row.map((cell, ci) => ({
      text: cell,
      options: { color: C.white, fontSize: 12, fill: { color: ri % 2 === 0 ? C.darkPanel : C.midPanel }, align: "center", valign: "middle" }
    })));
  });
  slide.addTable(tableRows, {
    x: 0.2, y: 1.0, w: 9.6, h: 4.3,
    border: { type: "solid", color: C.midPanel, pt: 1 },
    colW: headers.map(() => 9.6 / headers.length),
  });
  return slide;
}

function statSlide(title, stats, note) {
  const slide = pres.addSlide();
  addBg(slide, C.navy);
  slide.addShape(pres.ShapeType.rect, {
    x: 0, y: 0, w: "100%", h: 0.85,
    fill: { color: C.darkPanel },
    line: { type: "none" },
  });
  slide.addText(title, {
    x: 0.3, y: 0.0, w: 9.4, h: 0.85,
    fontSize: 24, bold: true, color: C.white, fontFace: "Calibri",
    align: "left", valign: "middle", margin: [0, 0, 0, 10],
  });
  const statW = 9.6 / stats.length;
  stats.forEach((s, i) => {
    const x = 0.2 + i * statW;
    slide.addShape(pres.ShapeType.rect, {
      x: x + 0.05, y: 1.1, w: statW - 0.1, h: 3.7,
      fill: { color: C.darkPanel },
      line: { color: s.accent || C.teal, pt: 2 },
    });
    slide.addShape(pres.ShapeType.rect, {
      x: x + 0.05, y: 1.1, w: statW - 0.1, h: 0.12,
      fill: { color: s.accent || C.teal },
      line: { type: "none" },
    });
    slide.addText(s.value, {
      x: x + 0.1, y: 1.5, w: statW - 0.2, h: 1.4,
      fontSize: 40, bold: true, color: s.accent || C.teal, fontFace: "Calibri",
      align: "center", valign: "middle",
    });
    slide.addText(s.label, {
      x: x + 0.1, y: 2.95, w: statW - 0.2, h: 0.8,
      fontSize: 14, bold: true, color: C.white, fontFace: "Calibri",
      align: "center", valign: "middle",
    });
    if (s.sub) {
      slide.addText(s.sub, {
        x: x + 0.1, y: 3.75, w: statW - 0.2, h: 0.7,
        fontSize: 12, color: C.lightGray, fontFace: "Calibri",
        align: "center", valign: "middle",
      });
    }
  });
  if (note) {
    slide.addText(note, {
      x: 0.3, y: 5.0, w: 9.4, h: 0.4,
      fontSize: 12, italic: true, color: C.lightGray, fontFace: "Calibri",
      align: "left",
    });
  }
  return slide;
}

// ─── FETCH IMAGES ─────────────────────────────────────────────────────────────
const imageUrls = [
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_f4d5eaf24933b29e8fa9a4b854a4227b607e64958109fb6b1706457fd43ff563.jpg", // A-lines normal lung
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_2361a905b5ee7d261b1aaa27974ac8a6cc28b234d00d199a148f9c585988c67c.jpg", // lung pathology montage
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_c67e2603779eeea57bcdb7240722c74bca3e75505a6c979c5a18289bf3fc0568.jpg", // B-lines
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_26e17a26f9debd39079056141fde0c84b72e0100eb91c828b2c2e48af554634c.jpg", // IVC comparison
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_719d244fe6c1f89d25c161066c48d128afdec51da1f8cf13ae75928e17f7a21e.jpg", // cardiac tamponade
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_d108c09f9a5d3e6c0dbe5cb608170df96b8fd9ce0137eea6418effc3bd1c7ac3.jpg", // central line US
  "https://cdn.orris.care/cdss_images/a1171c9cf560bda44b6568f211435fb6cbdf769eeb5ef37193b7eebe19130f65.png", // M-mode sandy beach
  "https://cdn.orris.care/cdss_images/fdc2b866b58e85b8a946bba315ccd6b5089da846d57850a1edd86fb1370674db.png", // lung pathologies 4-panel
];

let images = [];
try {
  const out = execSync(
    `node /home/daytona/skills/shared/scripts/fetch_images.js ${imageUrls.map(u => `"${u}"`).join(" ")}`,
    { maxBuffer: 50 * 1024 * 1024 }
  ).toString();
  images = JSON.parse(out);
} catch(e) {
  console.error("Image fetch error:", e.message);
  images = imageUrls.map(u => ({ url: u, base64: null, error: "fetch failed" }));
}

function img(i) {
  return (images[i] && !images[i].error) ? images[i].base64 : "SKIP";
}

// ─── BUILD SLIDES ─────────────────────────────────────────────────────────────

// SLIDE 1 — TITLE
{
  const slide = pres.addSlide();
  addBg(slide, C.navy);
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.22, h: "100%", fill: { color: C.teal }, line: { type: "none" } });
  slide.addShape(pres.ShapeType.ellipse, { x: 7.2, y: -0.8, w: 5.5, h: 5.5, fill: { color: C.darkPanel }, line: { type: "none" } });
  slide.addShape(pres.ShapeType.ellipse, { x: 8.5, y: 3.2, w: 3.0, h: 3.0, fill: { color: C.midPanel }, line: { type: "none" } });
  slide.addText("POCUS", { x: 0.5, y: 0.8, w: 7, h: 1.5, fontSize: 64, bold: true, color: C.teal, fontFace: "Calibri", align: "left", margin: 0 });
  slide.addText("in the ICU", { x: 0.5, y: 2.2, w: 7, h: 0.9, fontSize: 42, bold: true, color: C.white, fontFace: "Calibri", align: "left", margin: 0 });
  slide.addShape(pres.ShapeType.rect, { x: 0.5, y: 3.2, w: 5, h: 0.06, fill: { color: C.gold }, line: { type: "none" } });
  slide.addText("Point-of-Care Ultrasound: Evidence-Based Applications\nfor the Attending Intensivist", {
    x: 0.5, y: 3.4, w: 7.5, h: 1.0,
    fontSize: 17, color: C.lightGray, fontFace: "Calibri", align: "left",
  });
  slide.addText("SCCM Guidelines 2024 | Advanced Protocol-Based Practice", {
    x: 0.5, y: 5.0, w: 7, h: 0.45,
    fontSize: 13, color: C.teal, fontFace: "Calibri", align: "left", italic: true,
  });
}

// SLIDE 2 — OUTLINE
contentSlide("Presentation Overview", [
  "1 · Introduction & Evidence Base — Why POCUS in the ICU",
  "2 · Equipment, Probes & Windows",
  "3 · Vascular Access (CVC, Arterial, DVT)",
  "4 · Lung Ultrasound — BLUE Protocol",
  "5 · Cardiac POCUS & Critical Care Echocardiography",
  "6 · Hemodynamic Assessment & Fluid Responsiveness",
  "7 · RUSH Protocol — Undifferentiated Shock",
  "8 · Specific Shock States",
  "9 · Cardiac Arrest — POCUS during ACLS",
  "10 · Advanced Applications (Optic Nerve, Diaphragm, Airway, Gastric)",
  "11 · POCUS Governance, Training & Competency",
  "12 · Limitations, Pitfalls & Future Directions",
]);

// SLIDE 3 — WHY POCUS
contentSlide("Why POCUS in the ICU?", [
  "Traditional physical examination has poor sensitivity/specificity in critically ill patients",
  "POCUS enables real-time, repeatable, bedside assessment — augmenting clinical decision-making",
  "Improving technology + decreasing cost → widening adoption and availability",
  "SCCM 2024 Guidelines: CCUS recommended in septic shock, acute dyspnea, cardiogenic shock, volume management",
  { text: "Conditional recommendation FOR CCUS to guide management in septic shock (low-quality evidence)", sub: true },
  { text: "Conditional recommendation FOR targeted volume management with CCUS vs usual care (improves mortality)", sub: true },
  "Core competency status: now required in critical care fellowship training (ACGME)",
  "Skill is not the end goal — integration with physiology and clinical reasoning is key",
]);

// SLIDE 4 — EVIDENCE STATS
statSlide("Evidence at a Glance — SCCM 2024 CCUS Focused Update", [
  { value: "5", label: "Clinical Scenarios", sub: "Cardiac arrest · Sepsis · Dyspnea · Volume · Cardiogenic shock", accent: C.teal },
  { value: "↓", label: "Mortality Signal", sub: "CCUS-guided volume management (meta-analysis 2025)", accent: C.green },
  { value: "1A", label: "Grade: Pneumothorax Dx", sub: "Outperforms supine CXR", accent: C.gold },
  { value: "1B", label: "Grade: US-guided CVC", sub: "Internal jugular / femoral", accent: C.orange },
], "Sources: SCCM Adult CCUS Guidelines 2024 | Miller's Anesthesia 10e | Sharif S et al. Crit Care Explor 2025");

// SLIDE 5 — SECTION DIVIDER: EQUIPMENT
sectionDivider("Equipment, Probes & Windows", "Selecting the right transducer for each application");

// SLIDE 6 — PROBES
tableSlide("Ultrasound Probe Selection Guide", 
  ["Probe", "Frequency", "Application", "Key Advantage"],
  [
    ["Phased-Array (Sector)", "2–5 MHz", "Cardiac, IVC, pleural", "Small footprint, rib-space access"],
    ["Curvilinear (Convex)", "2–5 MHz", "Abdominal, lung, FAST, IVC", "Deep penetration, wide field"],
    ["Linear (Vascular)", "7–15 MHz", "Vascular access, DVT, superficial", "High resolution, near-field"],
    ["Microconvex", "4–8 MHz", "Combined cardiac + lung", "Portable devices, versatile"],
    ["Endocavitary", "4–9 MHz", "Transesophageal (TEE) in ICU", "When TTE windows poor"],
  ], C.teal);

// SLIDE 7 — WINDOWS & VIEWS
twoColumnSlide(
  "Standard Cardiac Windows — POCUS",
  "Parasternal Views",
  [
    "Parasternal Long Axis (PLAX): LV, MV, AV, aortic root",
    "Parasternal Short Axis (PSAX): AV level → papillary level",
    "D-sign: RV pressure overload / PE",
  ],
  "Other Essential Windows",
  [
    "Apical 4-Chamber: LV/RV size and function",
    "Subcostal 4-Chamber: rapid tamponade screen",
    "Subcostal IVC: diameter + collapsibility",
    "Suprasternal: aortic arch",
    "PLAX/A4C: LVOT-VTI for cardiac output",
  ], C.teal, C.gold
);

// SLIDE 8 — SECTION DIVIDER: VASCULAR
sectionDivider("Vascular Access & DVT", "US-guided procedures — SCCM Grade 1A/1B");

// SLIDE 9 — VASCULAR ACCESS
contentSlide("Ultrasound-Guided Vascular Access", [
  "CVC placement: SCCM Grade 1A (internal jugular, femoral) | Grade 1B (general central venous access)",
  "Two techniques: short-axis (out-of-plane) vs long-axis (in-plane) needle visualization",
  { text: "Short-axis: superior visualization of surrounding structures, less training, higher success rate", sub: true },
  { text: "Long-axis: reduces posterior wall puncture; requires more skill", sub: true },
  "Real-time guidance preferred over pre-procedural landmark approach",
  "Arterial cannulation: SCCM Grade 2B — reduces time-to-cannulation and hematoma formation (meta-analysis RCTs)",
  { text: "Especially valuable in ICU: peripheral edema, PVD, weak pulses increase difficulty", sub: true },
  "Pre-procedure: confirm vessel patency, identify anatomy, rule out thrombosis",
  "Always confirm placement: trace wire/catheter in vessel before dilation",
]);

// SLIDE 10 — VASCULAR IMAGE
imageSlide(
  "US-Guided Internal Jugular Cannulation",
  img(5),
  "Left: Short-axis showing IJV and carotid artery. Middle: Needle in IJV lumen (long-axis). Right: Pre-existing DVT — contraindication to cannulation at that site."
);

// SLIDE 11 — DVT
contentSlide("DVT Diagnosis by POCUS in the ICU", [
  "DVT: common in ICU — VTE risk 30–45% without prophylaxis; risk of PE sequelae",
  "Traditional formal vascular ultrasound requires sonographer availability and delays diagnosis",
  "POCUS DVT exam: 2-point or 3-point compression technique",
  { text: "Compress common femoral, femoral, and popliteal veins — loss of compressibility = DVT", sub: true },
  { text: "Sensitivity 86%, specificity 96% — achievable even with limited experience (Miller's Anesthesia 10e)", sub: true },
  "SCCM recommendation: Grade 1B for DVT screening by ICU physician",
  "Reduces time-to-diagnosis, enables screening when sonographers unavailable (nights/weekends)",
  "Limitations: calf vein DVT, central DVT (iliac/SVC) not well-assessed by compression technique",
]);

// SLIDE 12 — SECTION DIVIDER: LUNG
sectionDivider("Lung Ultrasound & BLUE Protocol", "Rapid differentiation of acute respiratory failure");

// SLIDE 13 — LUNG US ARTIFACTS
contentSlide("Lung Ultrasound: Fundamental Artifacts", [
  "Normal lung: only pleural line visible — air prevents transmission beyond",
  "A-LINES: horizontal reverberation artifacts — equally spaced below pleural line → normal aeration or PTX",
  "LUNG SLIDING: shimmering of pleural line ('ants on a twig') → visceral & parietal pleura moving together",
  { text: "M-mode corollary: 'Sandy Beach' sign — horizontal lines (sky) + granular below (beach)", sub: true },
  "B-LINES ('comet tails'): vertical laser-like artifacts from pleural line to far field",
  { text: "1–2 per rib space in dependent zones = normal | ≥3 confluent = interstitial syndrome", sub: true },
  "LUNG POINT: transition zone between sliding & non-sliding — 100% specific for pneumothorax",
  "CONSOLIDATION: tissue-like pattern replacing air; ± air bronchograms",
]);

// SLIDE 14 — LUNG IMAGE A-lines
imageSlide(
  "Normal Lung: A-Line Profile",
  img(0),
  "Horizontal, equidistant A-lines below the pleural line indicate normally aerated lung. Lung sliding must also be confirmed. Absence of sliding + A-lines only → consider pneumothorax."
);

// SLIDE 15 — LUNG PATHOLOGIES IMAGE
imageSlide(
  "Lung Ultrasound Pathologies — Comparative Panel",
  img(7),
  "(A) Normal: A-lines + sliding. (B) Pleural effusion: anechoic space with floating atelectatic lung. (C) Confluent B-lines: alveolar-interstitial syndrome (pulmonary edema/DAH). (D) Consolidation with air bronchograms: pneumonia/ARDS."
);

// SLIDE 16 — B-LINES IMAGE
imageSlide(
  "B-Lines: Interstitial Syndrome",
  img(2),
  "Multiple comet-tail B-lines (vertical, hyperechoic, arising from pleural line) indicate pulmonary edema or interstitial lung disease. Confluent/coalescent B-lines = 'white lung' = severe alveolar-interstitial syndrome."
);

// SLIDE 17 — BLUE PROTOCOL TABLE
tableSlide("BLUE Protocol — Acute Dyspnea Differentiation",
  ["LUS Pattern", "Additional Finding", "Diagnosis"],
  [
    ["A-profile (A-lines + sliding)", "No DVT", "COPD / Asthma exacerbation"],
    ["A-profile (A-lines + sliding)", "DVT present", "Pulmonary Embolism"],
    ["B-profile (≥3 B-lines bilateral)", "None", "Cardiogenic Pulmonary Edema"],
    ["A/B-profile (mixed)", "None", "Pneumonia"],
    ["A-profile, no lung sliding", "Lung point present", "Pneumothorax"],
    ["C-profile (consolidation)", "Air bronchograms, fever", "Pneumonia / ARDS"],
    ["B-profile unilateral", "Effusion", "Pneumonia / Effusion"],
  ], C.teal
);

// SLIDE 18 — PNEUMOTHORAX
contentSlide("Pneumothorax — Diagnosis by POCUS", [
  "Most common pathology where LUS outperforms imaging: sensitivity > supine CXR (Grade 1A)",
  "Findings: ABSENT lung sliding + ABSENT B-lines + PREDOMINANT A-lines",
  "M-mode: 'Barcode sign' (stratosphere sign) — replaces sandy beach pattern",
  "Lung POINT: transition between sliding and non-sliding — 100% specific vs CT scan",
  { text: "False positives: pleurodesis, adhesions, bronchial intubation, dense consolidation", sub: true },
  "False negatives: extensive subcutaneous emphysema, anterior pneumothorax in unusual location",
  "Clinical pearl: always scan bilaterally; compare sides",
  "In tension PTX: absent sliding + tracheal deviation + hemodynamic compromise → emergent decompression",
]);

// SLIDE 19 — SECTION DIVIDER: CARDIAC
sectionDivider("Cardiac POCUS & Critical Care Echocardiography", "Focused, repeatable, bedside hemodynamic interrogation");

// SLIDE 20 — CARDIAC POCUS OVERVIEW
contentSlide("Cardiac POCUS: What Can the Intensivist Assess?", [
  "Left ventricular systolic function: global (EF) and regional wall motion abnormalities",
  "Right ventricular size and function: D-sign, TAPSE, McConnell's sign (PE)",
  "Pericardial effusion and tamponade physiology",
  "Inferior vena cava: diameter + respiratory variation (volume status)",
  "Gross valvular pathology: severe MR, AR, stenosis",
  "Volume responsiveness: LVOT-VTI, passive leg raise response",
  "Intracardiac masses / thrombus",
  "Filling pressures: E/e' ratio (advanced CCE)",
  "CRITICAL: CCE findings must be integrated with full clinical picture — isolated findings lack specificity",
]);

// SLIDE 21 — CARDIAC TAMPONADE IMAGE
imageSlide(
  "Cardiac Tamponade — Subcostal View",
  img(4),
  "Anechoic pericardial effusion (*) surrounding cardiac silhouette. Arrow: right ventricular/atrial wall collapse during diastole — hallmark of tamponade physiology (obstructive shock). Plethoric non-collapsing IVC is an associated finding."
);

// SLIDE 22 — SHOCK TABLE: CARDIAC FINDINGS
tableSlide("Cardiac POCUS Findings in Shock States",
  ["Shock Type", "LV Function", "RV Function", "Pericardium", "IVC"],
  [
    ["Hypovolemic", "Hypercontractile, small cavity", "Normal", "Normal", "Flat (<1.5 cm), collapsing"],
    ["Cardiogenic", "Hypocontractile / dilated LV", "May be impaired", "Normal/effusion", "Plethoric, non-collapsing"],
    ["Obstructive (Tamponade)", "Normal / compensated", "Compressed", "Large effusion, RA/RV collapse", "Plethoric"],
    ["Obstructive (PE)", "Normal LV", "Dilated RV, D-sign, McConnell's", "Normal", "Plethoric"],
    ["Distributive (Sepsis)", "Hypercontractile (early) / depressed (late)", "Variable", "Normal", "Variable"],
  ], C.orange
);

// SLIDE 23 — SECTION DIVIDER: HEMODYNAMICS
sectionDivider("Hemodynamic Assessment & Fluid Responsiveness", "Beyond CVP — dynamic indices and functional hemodynamics");

// SLIDE 24 — IVC ASSESSMENT
contentSlide("IVC Assessment: Volume Status & Responsiveness", [
  "IVC imaged subcostally: longitudinal view, 1–2 cm from RA junction",
  "Diameter measurement: end-expiration (spontaneous breathing) or end-inspiration (ventilated)",
  "IVC Collapsibility Index (CI): (max–min) / max × 100%",
  { text: "CI >50% in SB patient → predicts fluid responsiveness (SVV surrogate)", sub: true },
  { text: "IVC <1.5 cm, CI >50% → low CVP, likely fluid-responsive", sub: true },
  { text: "Plethoric IVC (>2.1 cm, CI <20%) → elevated CVP, volume overload/RHF/tamponade/PE", sub: true },
  "Limitations in mechanical ventilation: CI less reliable at PEEP >10, tidal volume <8 mL/kg",
  "Dynamic test: Passive Leg Raise (PLR) + LVOT-VTI — >15% increase → fluid responder (sensitivity 85%)",
  "Superior to static CVP for predicting fluid response (Creasy & Resnik MFM; SCCM 2024)",
]);

// SLIDE 25 — IVC IMAGE
imageSlide(
  "IVC Diameter: Collapsed vs Plethoric",
  img(3),
  "Left: Flat/collapsed IVC = hypovolemia (fluid-responsive). Right: Plethoric, non-collapsing IVC = elevated CVP (cardiac tamponade, RHF, volume overload, PE). Critical component of RUSH protocol."
);

// SLIDE 26 — LVOT-VTI CARDIAC OUTPUT
contentSlide("Cardiac Output by POCUS: LVOT-VTI Method", [
  "Stroke Volume = LVOT area × LVOT VTI (velocity-time integral)",
  { text: "LVOT area = π × (D/2)² where D = LVOT diameter measured in PLAX view", sub: true },
  { text: "LVOT VTI = pulsed-wave Doppler in A5C or A3C view, sample volume just below AV", sub: true },
  "Cardiac Output (CO) = SV × Heart Rate",
  "Normal LVOT-VTI: 18–22 cm",
  "Serial measurements: 15% increase after passive leg raise or fluid challenge → volume responsiveness",
  "Clinical utility: guide vasopressors vs fluids in shock; monitor response to inotropes",
  "Limitations: requires good alignment, atrial fibrillation reduces accuracy",
  "Advanced CCE: E/e' ratio for LV filling pressures | TAPSE for RV systolic function",
]);

// SLIDE 27 — SECTION DIVIDER: RUSH
sectionDivider("RUSH Protocol — Undifferentiated Shock", "Rapid Ultrasound in Shock: Heart · Tank · Pipes");

// SLIDE 28 — RUSH TABLE
tableSlide("RUSH Protocol: Exam Sequence & Findings",
  ["RUSH Component", "Hypovolemic", "Cardiogenic", "Obstructive", "Distributive"],
  [
    ["HEART\n(Pump)", "Hypercontractile LV\nSmall LV cavity", "Hypocontractile/dilated LV\nPossible pericardial effusion", "Hypercontractile LV\nPericardial effusion\nRV strain (PE)", "Hyperdynamic (early)\nDepressed (late sepsis)"],
    ["TANK\n(IVC/Volume)", "Flat IVC\nFlat jugular veins\nPeritoneal/pleural fluid loss", "Distended IVC\nDistended JV\nPulmonary edema B-lines", "Distended IVC\nDistended JV\nPneumothorax", "Normal/small IVC (early)\nFluid loss"],
    ["PIPES\n(Aorta/DVT)", "Aortic aneurysm\nAortic dissection", "Normal", "DVT → PE", "Normal"],
  ], C.orange
);

// SLIDE 29 — RUSH WORKFLOW
contentSlide("RUSH Protocol: Clinical Workflow", [
  "Step 1 — Subcostal 4-chamber + IVC: Global LV/RV function + volume status (60 seconds)",
  "Step 2 — Parasternal long axis: LV function, pericardial effusion, valvular pathology",
  "Step 3 — Lung bilaterally (anterior): B-lines (edema), sliding (PTX), effusions",
  "Step 4 — Subcostal/epigastric: Abdominal aorta (AAA), free fluid (FAST)",
  "Step 5 — Lower extremities: Femoral and popliteal vein compressibility (DVT→PE)",
  { text: "Integrate findings: Is the pump failing? Is the tank empty or overloaded? Are the pipes obstructed?", sub: true },
  "Time target: complete RUSH within 3–5 minutes of patient contact",
  "Decision: Fluids / pressors / inotropes / pericardiocentesis / thrombolytics / decompression",
  "Re-examine after each intervention to guide escalation or de-escalation",
]);

// SLIDE 30 — SECTION DIVIDER: CARDIAC ARREST
sectionDivider("POCUS in Cardiac Arrest", "4H4T + Prognostication + CPR Integration");

// SLIDE 31 — CARDIAC ARREST
contentSlide("POCUS During Cardiac Arrest — ACLS Integration", [
  "Identify reversible causes: 4H4T — Hypovolemia, Hypoxia, Hypo/hyperkalemia, Hypothermia; Tamponade, Tension PTX, Thrombosis (PE/MI), Toxins",
  "Cardiac activity on POCUS during ACLS predicts higher ROSC (28.9% vs 7.2%) and survival to discharge (3.8% vs 0.6%)",
  { text: "Absence of cardiac activity + asystole on monitor: 5.9% survival to hospital admission (Gaspari et al.)", sub: true },
  "POCUS can identify organized electrical activity dissociated from mechanical activity (PEA)",
  "Best view: subcostal 4-chamber (probe does not interfere with chest compressions)",
  "CRITICAL: Pulse check ≤10 seconds — do not interrupt high-quality CPR for image acquisition",
  { text: "ICU/EM fellows obtain good-quality images 83% of time without interrupting CPR (simulator study)", sub: true },
  "POCUS guides termination-of-resuscitation decisions in PEA arrest (no cardiac activity = very poor prognosis)",
]);

// SLIDE 32 — SECTION DIVIDER: ADVANCED
sectionDivider("Advanced POCUS Applications", "Beyond the bedside basics");

// SLIDE 33 — ADVANCED APPLICATIONS
contentSlide("Advanced POCUS Applications in Critical Care", [
  "OPTIC NERVE SHEATH DIAMETER (ONSD): >5.0 mm = elevated ICP (>20 mmHg) — non-invasive ICP monitoring",
  { text: "Sensitivity ~90%, specificity ~85% for ICP >20 mmHg — useful when ICP monitor unavailable", sub: true },
  "DIAPHRAGM ULTRASOUND: M-mode excursion and thickening fraction — ventilator weaning assessment",
  { text: "Diaphragm thickening fraction <20–25% suggests diaphragm atrophy/dysfunction → prolonged weaning", sub: true },
  "GASTRIC ULTRASOUND: antral cross-sectional area — assess aspiration risk before extubation or procedures",
  "AIRWAY ULTRASOUND: confirm ETT placement (tracheal ring sliding), vocal cord movement, pre-procedural cricothyroid membrane ID",
  { text: "POCUS confirms ETT placement faster than clinical assessment (1.62 s vs 3.50 s for carotid pulse check)", sub: true },
  "ABDOMINAL/HEPATIC: free fluid (FAST), gallbladder, renal hydronephrosis, bladder volume",
  "ARTIFICIAL INTELLIGENCE: emerging tools for automated image acquisition + interpretation in ICU settings",
]);

// SLIDE 34 — SECTION DIVIDER: GOVERNANCE
sectionDivider("Training, Competency & Governance", "Building a credentialed POCUS program");

// SLIDE 35 — TRAINING PATHWAYS
twoColumnSlide(
  "POCUS Training & Credentialing Pathways",
  "Basic / Focused POCUS",
  [
    "Focused Cardiac Ultrasound (FoCUS)",
    "FAST / eFAST exam",
    "Vascular access",
    "Lung ultrasound basics",
    "Minimum: 50–100 supervised studies",
    "ACEP / AIUM basic competency",
    "Completion of formal curriculum + OSCE",
  ],
  "Critical Care Echocardiography (CCE)",
  [
    "Full CCUS scope: cardiac + lung + vascular + advanced apps",
    "Minimum 150–250 studies (CCE advanced: 300+)",
    "SCCM Critical Care Echocardiography certificate",
    "ASE/ACCP/ESICM recognized pathways",
    "Quality assurance: image archiving mandatory",
    "Ongoing: annual volume maintenance + CME",
    "Multidisciplinary QI program recommended",
  ], C.teal, C.gold
);

// SLIDE 36 — DOCUMENTATION
contentSlide("POCUS Documentation & Quality Assurance", [
  "All POCUS exams should be ARCHIVED — not just verbal reports",
  "Archiving is especially critical for advanced CCE (serial quantitative comparisons)",
  "Documentation requirements (ASE 2024 nomenclature paper):",
  { text: "Indication, probe type, views obtained, key measurements, clinical interpretation", sub: true },
  { text: "Quality of images (adequate/limited/non-diagnostic)", sub: true },
  "Separate POCUS documentation from standard TTE (cardiology-performed) in medical record",
  "Image storage: integrate with PACS or dedicated US workstation",
  "Peer review: 5–10% of studies reviewed for QA",
  "Pitfall: over-reliance on POCUS without appropriate clinical correlation — POCUS is a tool, not a diagnosis",
]);

// SLIDE 37 — SECTION DIVIDER: LIMITATIONS
sectionDivider("Limitations, Pitfalls & Future Directions", "Using POCUS safely and accurately");

// SLIDE 38 — LIMITATIONS & PITFALLS
twoColumnSlide(
  "Limitations & Common Pitfalls",
  "Technical Limitations",
  [
    "Poor acoustic windows: obesity, subcutaneous emphysema, dressings, ECMO cannulae",
    "Operator-dependent imaging and interpretation",
    "Artifact misidentification (A-lines vs PTX vs bullae)",
    "AF reduces VTI accuracy",
    "High PEEP invalidates IVC-based fluid assessment",
    "Tidal volume < 8 mL/kg reduces IVC variability index",
  ],
  "Clinical Pitfalls",
  [
    "Confirmation bias: seeking findings that match pre-test hypothesis",
    "Over-interpretation of non-diagnostic images",
    "Missing mixed shock states",
    "POCUS 'paralysis': delaying resuscitation for imaging",
    "Failure to re-examine after interventions",
    "Inadequate training → false-positive PTX (adhesions, intubation)",
  ], C.red, C.orange
);

// SLIDE 39 — FUTURE DIRECTIONS
contentSlide("Future Directions in Critical Care POCUS", [
  "Artificial Intelligence (AI): automated image optimization, pathology detection, real-time guidance",
  { text: "AI-assisted view classification, EF estimation, and LUS scoring — early promising results", sub: true },
  "Tele-POCUS: expert remote guidance of novice operators via video link (pandemic applications)",
  "Wearable/continuous POCUS: stick-on probes for continuous hemodynamic monitoring",
  "Extended applications: microcirculation assessment, transcranial Doppler, tumor POCUS",
  "Telemedicine integration: POCUS data streaming to remote intensivists",
  "Pandemic preparedness: ICU POCUS as primary diagnostic tool (COVID-19 experience)",
  "Standardization: ongoing efforts to harmonize POCUS nomenclature, training, and documentation globally (ASE 2024)",
]);

// SLIDE 40 — SUMMARY / KEY MESSAGES
{
  const slide = pres.addSlide();
  addBg(slide, C.navy);
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.85, fill: { color: C.darkPanel }, line: { type: "none" } });
  slide.addText("Key Takeaways — POCUS in the ICU", {
    x: 0.3, y: 0.0, w: 9.4, h: 0.85,
    fontSize: 24, bold: true, color: C.white, fontFace: "Calibri",
    align: "left", valign: "middle", margin: [0, 0, 0, 10],
  });
  const messages = [
    { num: "01", text: "POCUS is a core ICU competency — not optional; integrates physiology + clinical reasoning", accent: C.teal },
    { num: "02", text: "SCCM 2024: CCUS recommended for septic shock, dyspnea, cardiogenic shock, volume management", accent: C.gold },
    { num: "03", text: "Lung US (BLUE protocol) rapidly differentiates acute dyspnea; PTX: Grade 1A > supine CXR", accent: C.teal },
    { num: "04", text: "RUSH protocol: pump + tank + pipes — complete undifferentiated shock evaluation in <5 minutes", accent: C.gold },
    { num: "05", text: "IVC + PLR + LVOT-VTI: dynamic hemodynamic assessment superior to static CVP", accent: C.teal },
    { num: "06", text: "Archive all studies, maintain competency, integrate QA — avoid confirmation bias", accent: C.orange },
  ];
  const boxH = 0.67;
  messages.forEach((m, i) => {
    const y = 1.0 + i * (boxH + 0.08);
    slide.addShape(pres.ShapeType.rect, { x: 0.2, y, w: 9.6, h: boxH, fill: { color: C.darkPanel }, line: { type: "none" } });
    slide.addShape(pres.ShapeType.rect, { x: 0.2, y, w: 0.08, h: boxH, fill: { color: m.accent }, line: { type: "none" } });
    slide.addText(m.num, { x: 0.35, y, w: 0.55, h: boxH, fontSize: 18, bold: true, color: m.accent, fontFace: "Calibri", align: "center", valign: "middle" });
    slide.addText(m.text, { x: 0.95, y, w: 8.7, h: boxH, fontSize: 14, color: C.white, fontFace: "Calibri", align: "left", valign: "middle" });
  });
}

// SLIDE 41 — REFERENCES
contentSlide("Key References & Guidelines", [
  "SCCM Adult Critical Care Ultrasonography: Focused Update 2024 (Crit Care Med)",
  "Miller's Anesthesia 10th ed., Ch. 79 — POCUS in Critical Care (2023)",
  "Goldman-Cecil Medicine 27e — Shock and RUSH Protocol (2024)",
  "Basmaji J et al. POCUS-Guided Resuscitation in Shock: Systematic Review. Crit Care Med 2024 (PMID 39298556)",
  "Sharif S et al. CCUS for Volume Management: SR, MA, TSA. Crit Care Explor 2025 (PMID 40366291)",
  "Killu K et al. Echocardiography in Septic Shock: SR & MA. J Ultrasound 2025 (PMID 39419883)",
  "Kirkpatrick JN et al. ASE Recommendations: Cardiac POCUS Nomenclature. JASE 2024",
  "Lichtenstein DA. BLUE-Protocol and FALLS-Protocol. Chest 2015",
  "Barash Clinical Anesthesia 9e, Ch. 9 — POCUS in Anesthesiology Practice (2022)",
  "Creasy & Resnik Maternal-Fetal Medicine 8e — Fluid Responsiveness and POCUS (2022)",
]);

// ─── WRITE FILE ───────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/pocus-icu-ppt/POCUS_in_ICU.pptx" })
  .then(() => console.log("DONE: /home/daytona/workspace/pocus-icu-ppt/POCUS_in_ICU.pptx"))
  .catch(e => { console.error("ERROR:", e); process.exit(1); });