Orris

Let me introduce myself, I'm an pg emergency medicine resident 1 st year doing in Pudukkottai medical College, tamilnadu, I'll be asking you for guidance regarding all my cases, how to diagnose and treat, my thesis topics and journal club presentation everything

Welcome! It's great to meet you. Here's what you can expect from me as your clinical guidance partner throughout your PG residency:
What I can help you with:
1. Case-Based Guidance
  • Systematic approach to undifferentiated emergency presentations
  • Differential diagnosis frameworks
  • Investigations - what to order and how to interpret
  • Management protocols and drug dosing
  • Disposition decisions (admit/discharge/refer)
2. Thesis Support
  • Topic selection (feasible within your setting, ethical clearance considerations)
  • Study design advice (observational, prospective, interventional)
  • Sample size and methodology guidance
  • Literature review and recent evidence from PubMed
  • Writing and structuring chapters
3. Journal Club Presentations
  • Critical appraisal of RCTs, systematic reviews, observational studies
  • PICO framework breakdowns
  • Statistical concepts (NNT, OR, HR, confidence intervals, p-values)
  • Putting evidence in clinical context
4. Exam Preparation
  • DNB/MD Emergency Medicine theory topics
  • Viva voce preparation
  • Procedural knowledge (RSI, FAST, central lines, etc.)
A few things to know:
  • I draw from authoritative medical textbooks in my library, current PubMed literature, and up-to-date clinical guidelines
  • For drug dosing and protocols, I'll always flag when local/institutional guidelines may differ
  • I'll be direct and evidence-based - I won't just validate your thinking if I disagree
  • For complex cases, I'll reason through them systematically rather than jump to answers
To get started - just present a case, ask a clinical question, drop a journal article, or tell me your thesis ideas. The more context you give (patient details, what you're thinking, what you've already done), the more useful my guidance will be.
What's your first question?

Thank you so much I got to do a presentation on local anesthesia in emergency medicine department

Asking for Preferences
Reading File
Finding Sources
Finding Sources
Searching PubMed

local anesthesia emergency department nerve blocks

Reading File
Reading File
Finding Sources
Reading File
Finding Sources
Excellent - I now have rich material from Tintinalli's Emergency Medicine (the gold standard EM textbook). Let me compile the full presentation content.

🏥 Local Anesthesia in Emergency Medicine

A Comprehensive Presentation Guide

Tintinalli's Emergency Medicine (9th Ed.) | Pfenninger & Fowler's Procedures for Primary Care | Katzung Pharmacology

SUGGESTED PRESENTATION STRUCTURE (45 minutes)

SLIDE 1 - Title Slide

Local Anesthesia in Emergency Medicine The Foundation of Pain-Free Procedures Presenter: [Your Name], PG Year 1 Department of Emergency Medicine, Pudukkottai Medical College

SLIDE 2 - Why This Matters in the ED

  • The ED is the highest-volume procedural setting in any hospital
  • Nearly every ED procedure requires some form of local anesthesia:
    • Wound repair, abscess drainage, fracture reduction, lumbar puncture, IV access, chest tube, thoracentesis
  • Inadequate analgesia = poor patient experience, increased complications, failure of procedures
  • LA toxicity is life-threatening and must be recognized and managed immediately

SLIDE 3 - Learning Objectives

By the end of this session, you will be able to:
  1. Classify local anesthetics and explain their mechanism of action
  2. Select the right agent for the right procedure with correct dosing
  3. Recognize and manage local anesthetic systemic toxicity (LAST)
  4. Describe topical, infiltration, and nerve block techniques used in the ED
  5. Know the contraindications and special considerations

SECTION 1: PHARMACOLOGY

SLIDE 4 - Classification of Local Anesthetics

ClassExamplesMetabolismMemory Aid
EstersProcaine, Tetracaine, Benzocaine, CocainePlasma cholinesterase (pseudocholinesterase)"PTBC" - one 'i' in ester
AmidesLidocaine, Bupivacaine, Ropivacaine, Mepivacaine, PrilocaineHepatic microsomal enzymesAll have two 'i's in their names
Clinical pearl: Patients with pseudocholinesterase deficiency (e.g., liver disease, pregnancy) have prolonged ester metabolism. Amides are preferred in these patients.
Allergy pearl: True allergy to amides is extremely rare. Most "allergic reactions" to LA are actually vasovagal reactions or epinephrine effects. Cross-reactivity between amide and ester classes does NOT occur.

SLIDE 5 - Mechanism of Action

Core mechanism: Reversible blockade of voltage-gated sodium (Na⁺) channels
  • Bind to the internal face of the Na⁺ channel in its inactivated state
  • Prevent Na⁺ influx → no depolarization → no action potential propagation
  • Effect is use-dependent (more firing = more blockade)
Differential nerve fiber sensitivity (order of blockade):
  1. Small unmyelinated C fibers (pain, temperature) - blocked FIRST
  2. Small myelinated A-delta fibers (fast pain, cold)
  3. Large myelinated A-beta (touch, pressure)
  4. A-alpha (motor) - blocked LAST
Clinical pearl: This explains why patients can feel touch/pressure but not pain during adequate local anesthesia - the classic "pressure not pain" sensation.

SLIDE 6 - Key Pharmacokinetic Properties

PropertyDeterminesKey Concept
pKaSpeed of onsetLower pKa → more non-ionized form at physiologic pH → faster membrane penetration → faster onset
Protein bindingDuration of actionHigher protein binding → longer receptor affinity → longer duration (bupivacaine >95% protein bound)
Lipid solubilityPotencyHigher lipid solubility → penetrates nerve membrane better → more potent
pKa summary:
  • Lidocaine pKa = 7.9 → Fast onset (most popular in ED)
  • Bupivacaine pKa = 8.1 → Slower onset but longer duration
Why infected tissues are hard to anesthetize: Inflamed/infected tissue has lower pH (acidic environment). This increases ionization of LA → less diffuses across membranes → poor block. Always inject into non-infected tissue surrounding the area, not directly into the abscess.

SLIDE 7 - Commonly Used Agents in the ED

AgentClassOnsetDuration (plain)Duration (+ epi)Max Dose (plain)Max Dose (+ epi)
Lidocaine 1-2%AmideFast (2-5 min)30-60 min2-4 hours4.5 mg/kg (300 mg)7 mg/kg (500 mg)
Bupivacaine 0.25-0.5%AmideSlow (5-10 min)4-8 hoursUp to 12 hours2.5 mg/kg (175 mg)3 mg/kg (225 mg)
Ropivacaine 0.2-0.75%AmideIntermediate3-8 hours-3 mg/kg-
Procaine 1-2%EsterSlow15-30 min30-90 min600 mg-
ED workhorse: Lidocaine 1% is the go-to for most ED procedures. Use bupivacaine when prolonged analgesia is needed (e.g., fractures, post-procedure pain control).
How to calculate: 1% solution = 10 mg/mL. So for a 70 kg patient: max plain lidocaine = 4.5 × 70 = 315 mg ≈ 31.5 mL of 1% lidocaine.

SLIDE 8 - Role of Epinephrine

Benefits of adding epinephrine (1:100,000 to 1:200,000):
  • Causes local vasoconstriction → slows systemic absorption
  • Prolongs duration of action (up to double)
  • Allows higher total dose of LA
  • Reduces bleeding at procedure site (improves visualization)
Contraindications to epinephrine - the "classic 5":
  1. Digits (fingers, toes) - risk of ischemia (though recent evidence shows low-risk in healthy patients)
  2. Penis (dorsal nerve block)
  3. Nose tip (ala)
  4. Earlobes
  5. Infected/contaminated wounds (increases infection risk via ischemia)
Additional cautions: Peripheral vascular disease, uncontrolled hypertension, thyrotoxicosis, patients on MAO inhibitors

SECTION 2: LOCAL ANESTHETIC SYSTEMIC TOXICITY (LAST)

SLIDE 9 - LAST: Overview

LAST results from excessive plasma levels of local anesthetic due to:
  • Accidental intravascular injection (most common)
  • Relative overdose (too high total dose)
  • Rapid absorption from highly vascular areas (intercostal > epidural > brachial plexus > femoral > subcutaneous)
Risk factors:
  • Extremes of age (elderly, neonates)
  • Low lean body mass
  • Hepatic dysfunction (amides)
  • Cardiac disease, conduction abnormalities
  • Metabolic acidosis
  • High-volume nerve blocks (e.g., TAPB, pectoral blocks)

SLIDE 10 - LAST: Clinical Progression

CNS symptoms appear BEFORE cardiovascular symptoms (lower threshold):
MILD (CNS excitation)
├── Circumoral numbness/tingling
├── Metallic taste in mouth
├── Tinnitus, light-headedness
├── Visual disturbances
└── Restlessness, agitation

MODERATE (CNS depression)
├── Slurred speech
├── Drowsiness
└── Muscle twitching

SEVERE
├── Generalized tonic-clonic seizures
├── Loss of consciousness
└── ↓↓ CARDIOVASCULAR COLLAPSE ↓↓
    ├── Bradycardia
    ├── Conduction block / Widened QRS
    ├── VT / VF
    └── Asystole
Important: Bupivacaine can cause cardiovascular collapse with MINIMAL preceding CNS signs - this is why bupivacaine is the most dangerous agent.

SLIDE 11 - LAST: Management (The EM Critical Protocol)

STOP injecting. Call for help. Airway first.
Step 1: Seizures
  • Benzodiazepines (first-line): Midazolam 0.05-0.1 mg/kg IV or Lorazepam 0.05 mg/kg IV
  • If refractory: Propofol (small doses) or thiopentone
  • Avoid succinylcholine (masks ongoing seizure activity on EEG)
Step 2: Cardiac Arrest
  • Standard ACLS/BLS
  • Modified epinephrine dosing: 10-100 mcg IV (NOT the standard 1 mg dose - high-dose epi worsens outcomes with LAST)
  • Avoid: Vasopressin, calcium channel blockers, beta-blockers, lidocaine (as antiarrhythmic)
Step 3: INTRAVENOUS LIPID EMULSION (ILE) - The Antidote
20% Lipid Emulsion (Intralipid®) Protocol:
  • Bolus: 1.5 mL/kg IV over 1 minute (= ~100 mL for 70 kg patient)
  • Infusion: 0.25 mL/kg/min for at least 10 minutes after hemodynamic stability
  • Repeat bolus if cardiac instability persists (up to 3 boluses)
  • Maximum dose: ~10 mL/kg over first 30 minutes
Mechanism of ILE: "Lipid sink" theory - the lipid phase in plasma sequesters the highly lipid-soluble LA (especially bupivacaine) away from cardiac/CNS tissues

SECTION 3: TECHNIQUES IN THE ED

SLIDE 12 - Routes of Local Anesthesia in the ED

LOCAL ANESTHESIA IN EM
│
├── 1. TOPICAL (no injection)
│   ├── Intact skin: EMLA, LMX
│   └── Open wounds/mucosa: LET, viscous lidocaine, benzocaine spray
│
├── 2. LOCAL INFILTRATION
│   ├── Direct wound infiltration
│   └── Field block
│
└── 3. REGIONAL (NERVE BLOCKS)
    ├── Peripheral nerve blocks
    └── Intravenous regional (Bier block)

SLIDE 13 - Topical Agents (Great for Pediatric ED)

AgentIndicationHow to UseTime to Work
EMLA (Lidocaine 2.5% + Prilocaine 2.5%)IV access, minor procedures on intact skinThick layer under occlusive dressing60 minutes
LMX 4% (Liposomal lidocaine)IV access, venipunctureApply 2.5 g, cover30-60 min
LET (Lidocaine 4% + Epi 0.1% + Tetracaine 0.5%)Facial/scalp lacerations in children3-5 mL on gauze, apply to wound20-30 min
Viscous lidocaine 2%Pharyngeal procedures, NG tube insertionGargle/apply 10 mL2-5 min
Benzocaine spray 20%Airway procedures, oral mucosa1 spray15-30 sec
Pediatric pearl: LET is outstanding for pediatric facial lacerations - apply it while you gather your suture kit and the child is nearly anesthetized by the time you're ready. No needle, no tears.
Warning: Benzocaine and prilocaine can cause methemoglobinemia - monitor SpO₂ in infants and at-risk patients.

SLIDE 14 - Local Infiltration Technique

Principles for minimizing injection pain:
  1. Use the smallest needle possible (25-30G)
  2. Inject slowly (slow injection hurts less than fast)
  3. Buffer with sodium bicarbonate - add 1 mL of 8.4% NaHCO₃ to 9 mL lidocaine (raises pH → more non-ionized form → less sting + faster onset)
  4. Use warmed solution (body temperature)
  5. Inject through wound edges (not intact skin) when possible
  6. Use a slow, fanning technique for field blocks
Wound infiltration: Inject into the subcutaneous tissue at wound edges. The needle tip should always be in tissue already anesthetized before advancing.
Field block: A ring of LA is deposited around the area (not directly into it) - useful for infected areas, tumors, or when direct injection would distort anatomy (e.g., facial lacerations before repair).

SLIDE 15 - Key Nerve Blocks Used in the ED

These provide superior analgesia with less drug and no tissue distortion:
BlockIndicationLandmark/Approach
Digital nerve blockFinger/toe laceration, nail procedures, paronychiaWeb space injection or volar approach
Median/Ulnar/Radial nerve block at wristHand lacerations/proceduresAnatomical landmark-based
Femoral nerve blockFemoral shaft fracture, hip painBelow inguinal ligament, lateral to femoral artery
Fascia iliaca blockHip fracture (NOF), femoral shaft #1 cm below inguinal ligament, 2/3 lateral point
Hematoma blockDistal radius fracture, fracture reductionDirect injection into fracture hematoma
Dental blocks (inferior alveolar)Mandibular fracture, dental painIntraoral approach
Supra/infraorbital blockForehead/cheek lacerationMidpupillary line, orbital notch
Posterior tibial nerve blockPlantar foot proceduresBehind medial malleolus
Intercostal nerve blockRib fractures, thoracic painBelow rib at posterior axillary line

SLIDE 16 - Fascia Iliaca Block (High-Yield ED Block)

The fascia iliaca compartment block (FICB) deserves special attention - it's increasingly being done in ED for hip fractures and is often the first block an EM resident learns.
Why in the ED?
  • Hip fractures (NOF #) are extremely painful
  • Opioids in elderly = delirium, respiratory depression, constipation
  • FICB provides equivalent or superior analgesia to IV morphine
Landmark technique:
  1. Draw a line from ASIS to pubic tubercle
  2. Find the junction of lateral 1/3 and medial 2/3
  3. Go 1 cm inferior to this point
  4. Use a "two-pop" technique through fascia lata, then fascia iliaca
  5. Inject 30-40 mL of 0.25% bupivacaine (or 0.375% ropivacaine)
Recent evidence: A 2025 scoping review in AJEM (Gawel et al.) specifically reviewed emergency physician-performed ultrasound-guided nerve blocks, confirming safety and efficacy of ED-performed regional anesthesia.

SLIDE 17 - Hematoma Block

Indication: Distal radius fractures (Colles'), other closed fractures requiring reduction
Technique:
  1. Identify fracture site on X-ray
  2. Clean the overlying skin
  3. Insert a 21-23G needle perpendicular into the fracture site
  4. Aspirate to confirm hematoma blood (confirms intra-hematoma position)
  5. Inject 5-10 mL of 1-2% lidocaine (plain, no epi)
  6. Wait 10-15 minutes for full effect
Advantages: Simple, no special equipment, single-operator, effective Contraindications: Open fractures, overlying skin infection

SECTION 4: SPECIAL TOPICS

SLIDE 18 - Reducing Pain of Injection

The injection itself is often what patients fear most. Evidence-based techniques:
  1. Buffering (most effective): Add 1 mL sodium bicarbonate (8.4%) to 9 mL of 1% lidocaine → raises pH → more active base form → less stinging, faster onset
  2. Warm solution: Warm to body temperature (37°C)
  3. Fine needle: 27-30G for face, 25G elsewhere
  4. Slow injection: Rate matters - inject 1 mL per 10 seconds
  5. EMLA pre-application for pediatric patients 45-60 min before
  6. Topical ice/vapocoolant spray before needle insertion
  7. Distract patient: The Gate Control Theory - concurrent stimulation reduces pain perception

SLIDE 19 - Special Populations

Pregnant patients:
  • Lidocaine is safe (Category B equivalent)
  • Avoid high doses of bupivacaine (cardiotoxicity risk is higher)
  • All LAs cross the placenta
Pediatric dosing (CRITICAL - weight-based):
  • Lidocaine: Max 4.5 mg/kg (plain) - NO more than this
  • Always calculate in mg, then convert to mL
  • Topical LET preferred for facial lacerations to avoid injection
Elderly patients:
  • Reduced protein binding → higher free drug levels → increased toxicity risk
  • Reduce doses by 25-30%
  • Prefer shorter-acting agents
Hepatic dysfunction:
  • Amides are hepatically metabolized → accumulate
  • Use lower doses, consider ester alternatives
Pseudocholinesterase deficiency (rare):
  • Cannot metabolize esters → prolonged effect and toxicity
  • Use amides

SLIDE 20 - Methemoglobinemia from LA

Agents: Benzocaine (highest risk), Prilocaine, EMLA Mechanism: Oxidation of Fe²⁺ (ferrous) hemoglobin to Fe³⁺ (ferric) = methemoglobin → cannot carry O₂
Presentation:
  • Cyanosis despite high-flow O₂
  • SpO₂ falsely reads ~85% (co-oximetry needed)
  • Chocolate-brown blood
  • Headache, fatigue → severe: altered consciousness, seizures
Treatment:
  • Methylene blue 1-2 mg/kg IV over 5 minutes (reduces MetHb back to Hb)
  • High-flow 100% O₂
  • Avoid methylene blue in G6PD deficiency (causes hemolysis) → use ascorbic acid instead

SLIDE 21 - Summary Table: Quick Reference for the ED

ScenarioAgent of ChoiceDose
Quick suture (< 1 hour)Lidocaine 1% plain4.5 mg/kg
Post-procedure analgesia neededBupivacaine 0.25%2.5 mg/kg
Vascular area (need higher dose)Lidocaine 1% + epi 1:100,0007 mg/kg
Pediatric facial lacerationLET topical gelStandard dosing
Hip/NOF fractureFascia iliaca block (bupivacaine 0.25%)30-40 mL
Distal radius fractureHematoma block (lidocaine 1%)5-10 mL
LAST with cardiac arrestILE 20% (Intralipid)1.5 mL/kg bolus

SLIDE 22 - Key Take-Home Points

  1. Know your drugs: Amides are your ED workhorses (lidocaine, bupivacaine). Metabolized in the liver. Two 'i's = amide.
  2. Calculate before you inject: Always calculate max dose in mg based on patient weight.
  3. Epi is your friend - except in end-organ vessels (digits, penis, nose, ears) and infected tissue.
  4. Infected tissue resists LA - because acidic pH increases ionization. Inject around, not in.
  5. LAST is life-threatening - know the signs (tinnitus → metallic taste → seizures → cardiac arrest) and have Intralipid 20% in your department.
  6. Nerve blocks are underused in EM - fascia iliaca blocks, hematoma blocks, and digital blocks are simple, effective, and spare opioids.
  7. Methemoglobinemia - think of it when a patient is "blue" despite O₂, especially after benzocaine/prilocaine use. Treat with methylene blue.

SLIDE 23 - References

  1. Tintinalli JE et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9th Ed. McGraw-Hill. Chapter 36: Local and Regional Anesthesia.
  2. Pfenninger JL, Fowler GC. Procedures for Primary Care, 3rd Ed. Elsevier. Chapter 4: Local Anesthesia.
  3. Gawel RJ et al. Emergency physician-performed ultrasound-guided nerve blocks: A scoping review. Am J Emerg Med. 2025 Nov. PMID: 40773853
  4. Gamberini L et al. Regional anesthesia in blunt thoracic trauma: Systematic review and Bayesian network meta-analysis. Am J Emerg Med. 2025 Mar. PMID: 39740311
  5. Bailey JG et al. Local anesthetic dosing for fascial plane blocks to avoid systemic toxicity. Can J Anaesth. 2025 Sep. PMID: 40954415

BONUS: Viva/Exam Questions on This Topic

  1. What is the maximum dose of lidocaine with and without epinephrine?
  2. Why does local anesthetic not work well in infected tissue?
  3. What is the antidote for LAST? What is the dose?
  4. Why is bupivacaine cardiotoxic?
  5. A patient develops cyanosis after benzocaine spray for bronchoscopy. SpO₂ = 85% despite O₂. Diagnosis and treatment?
  6. Difference between field block and nerve block?
  7. What is the mechanism of action of epinephrine when added to LA?
  8. Name the nerve blocks commonly performed in the ED.
Presentation tips:
  • Start with a case vignette (e.g., 7-year-old child with facial laceration - how do you anesthetize?) to grab attention
  • Use the LAST progression diagram as a visual slide
  • End with a live demonstration of digital nerve block technique if possible
  • Keep the "calculate before you inject" message as a running theme
Want me to convert this into a PowerPoint (PPTX) file for you, or expand any specific section further?

Yes ppt

Reading File
Reading File
Reading File
Reading File
Running Command

ls /home/daytona/workspace/ 2>/dev/null && mkdir -p /home/daytona/workspace/loca…

Writing File

~/local-anesthesia-em/build.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Local Anesthesia in Emergency Medicine";
pres.author = "PG Year 1, Emergency Medicine, Pudukkottai Medical College";

// ─── PALETTE ───────────────────────────────────────────────────────────────
const C = {
  navy:       "0A1628",   // dominant dark bg
  navyMid:    "0D2240",   // slightly lighter navy
  navyLight:  "1A3A5C",   // card bg
  red:        "C0392B",   // accent – danger/toxicity
  orange:     "E67E22",   // accent – caution
  teal:       "17A589",   // accent – positive/clinical
  gold:       "F1C40F",   // highlight
  white:      "FFFFFF",
  lightGray:  "ECF0F1",
  midGray:    "95A5A6",
  textLight:  "D5E8F5",
  sectionBar: "C0392B",   // section divider colour
};

// ─── HELPER: section divider slide ─────────────────────────────────────────
function sectionSlide(title, subtitle, num) {
  const sl = pres.addSlide();
  sl.background = { color: C.navy };
  // left accent bar
  sl.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C.red }, line: { color: C.red } });
  // big number watermark
  sl.addText(String(num), {
    x: 6.5, y: 0.2, w: 3.3, h: 5.0,
    fontSize: 200, bold: true, color: "FFFFFF", transparency: 92, align: "right", valign: "middle"
  });
  sl.addText(title, { x: 0.55, y: 1.6, w: 8.5, h: 1.2, fontSize: 40, bold: true, color: C.white, fontFace: "Calibri" });
  if (subtitle) {
    sl.addText(subtitle, { x: 0.55, y: 2.85, w: 8.0, h: 0.6, fontSize: 18, color: C.textLight, fontFace: "Calibri" });
  }
  return sl;
}

// ─── HELPER: content slide with header bar ──────────────────────────────────
function contentSlide(title, accentColor) {
  const sl = pres.addSlide();
  sl.background = { color: "F7FAFD" };
  // top header bar
  sl.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.75, fill: { color: accentColor || C.navyMid }, line: { color: accentColor || C.navyMid } });
  // left accent strip
  sl.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0.75, w: 0.08, h: 4.875, fill: { color: accentColor || C.teal }, line: { color: accentColor || C.teal } });
  sl.addText(title, { x: 0.3, y: 0.07, w: 9.4, h: 0.62, fontSize: 22, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
  return sl;
}

// ─── HELPER: add pill/badge ──────────────────────────────────────────────────
function addBadge(sl, text, x, y, w, bgColor, textColor) {
  sl.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w, h: 0.3, fill: { color: bgColor }, line: { color: bgColor }, rectRadius: 0.08 });
  sl.addText(text, { x, y, w, h: 0.3, fontSize: 10, bold: true, color: textColor || C.white, align: "center", valign: "middle" });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 1 – TITLE
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.navy };

  // Top red stripe
  sl.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.08, fill: { color: C.red }, line: { color: C.red } });
  // Bottom red stripe
  sl.addShape(pres.shapes.RECTANGLE, { x: 0, y: 5.545, w: 10, h: 0.08, fill: { color: C.red }, line: { color: C.red } });

  // Central white card
  sl.addShape(pres.shapes.RECTANGLE, {
    x: 0.6, y: 0.6, w: 8.8, h: 4.4,
    fill: { color: C.navyLight },
    shadow: { type: "outer", color: "000000", blur: 20, offset: 4, angle: 135, opacity: 0.4 }
  });

  // Red left accent
  sl.addShape(pres.shapes.RECTANGLE, { x: 0.6, y: 0.6, w: 0.22, h: 4.4, fill: { color: C.red }, line: { color: C.red } });

  sl.addText("LOCAL ANESTHESIA", {
    x: 1.1, y: 0.9, w: 8.0, h: 0.8,
    fontSize: 38, bold: true, color: C.white, charSpacing: 4, fontFace: "Calibri"
  });
  sl.addText("IN EMERGENCY MEDICINE", {
    x: 1.1, y: 1.65, w: 8.0, h: 0.6,
    fontSize: 28, bold: false, color: C.teal, fontFace: "Calibri", charSpacing: 2
  });

  // Divider line
  sl.addShape(pres.shapes.RECTANGLE, { x: 1.1, y: 2.38, w: 7.5, h: 0.025, fill: { color: C.midGray }, line: { color: C.midGray } });

  sl.addText("Pharmacology  |  Techniques  |  Nerve Blocks  |  LAST Management", {
    x: 1.1, y: 2.55, w: 8.0, h: 0.4,
    fontSize: 13, color: C.textLight, fontFace: "Calibri", align: "left"
  });

  sl.addText([
    { text: "Presenter: ", options: { bold: true, color: C.gold } },
    { text: "PG Year 1, Emergency Medicine", options: { color: C.textLight } },
  ], { x: 1.1, y: 3.15, w: 8.0, h: 0.35, fontSize: 14, fontFace: "Calibri" });

  sl.addText([
    { text: "Department of Emergency Medicine\n", options: { color: C.textLight } },
    { text: "Pudukkottai Medical College, Tamil Nadu", options: { color: C.textLight } },
  ], { x: 1.1, y: 3.5, w: 8.0, h: 0.65, fontSize: 13, fontFace: "Calibri" });

  sl.addText("July 2026", { x: 1.1, y: 4.25, w: 2, h: 0.35, fontSize: 12, color: C.midGray });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 2 – WHY THIS MATTERS
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("Why Local Anesthesia Matters in the ED", C.navyMid);

  const cards = [
    { icon: "🔪", title: "Highest procedure volume", body: "Wound repair, abscess drainage, fracture reduction, LP, chest tube — all need LA" },
    { icon: "😰", title: "Pain is the #1 ED complaint", body: "Adequate analgesia = better outcomes, patient cooperation, procedure success" },
    { icon: "⚠️", title: "LAST is life-threatening", body: "Toxicity from LA can cause refractory seizures & cardiac arrest — must be recognized fast" },
    { icon: "💊", title: "Opioid-sparing strategy", body: "Regional blocks reduce or replace opioid use — critical in elderly & polytrauma patients" },
  ];

  cards.forEach((c, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = 0.25 + col * 4.9;
    const y = 0.95 + row * 2.15;
    sl.addShape(pres.shapes.RECTANGLE, {
      x, y, w: 4.6, h: 1.9,
      fill: { color: C.navyLight },
      shadow: { type: "outer", color: "000000", blur: 8, offset: 2, angle: 135, opacity: 0.2 }
    });
    sl.addShape(pres.shapes.RECTANGLE, { x, y, w: 0.12, h: 1.9, fill: { color: C.teal }, line: { color: C.teal } });
    sl.addText(c.icon + "  " + c.title, {
      x: x + 0.2, y: y + 0.15, w: 4.2, h: 0.4,
      fontSize: 14, bold: true, color: C.gold, fontFace: "Calibri"
    });
    sl.addText(c.body, {
      x: x + 0.2, y: y + 0.55, w: 4.2, h: 1.15,
      fontSize: 12, color: C.lightGray, fontFace: "Calibri", wrap: true
    });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 3 – LEARNING OBJECTIVES
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("Learning Objectives", C.navyMid);

  const objectives = [
    "Classify local anesthetics and explain their mechanism of action",
    "Select the correct agent for each ED procedure with accurate dosing",
    "Recognize and manage Local Anesthetic Systemic Toxicity (LAST)",
    "Describe topical, infiltration, and nerve block techniques",
    "Know contraindications including epinephrine and special populations",
  ];

  objectives.forEach((obj, i) => {
    const y = 0.95 + i * 0.88;
    // Number circle
    sl.addShape(pres.shapes.ELLIPSE, { x: 0.2, y: y, w: 0.45, h: 0.45, fill: { color: C.red }, line: { color: C.red } });
    sl.addText(String(i + 1), { x: 0.2, y: y, w: 0.45, h: 0.45, fontSize: 14, bold: true, color: C.white, align: "center", valign: "middle" });
    sl.addShape(pres.shapes.RECTANGLE, {
      x: 0.78, y: y + 0.03, w: 8.9, h: 0.42,
      fill: { color: i % 2 === 0 ? "E8F4F8" : C.lightGray },
      line: { color: i % 2 === 0 ? "D0E8F2" : "DCDCDC" }
    });
    sl.addText(obj, {
      x: 0.95, y: y + 0.03, w: 8.6, h: 0.42,
      fontSize: 13.5, color: C.navy, fontFace: "Calibri", valign: "middle"
    });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SECTION DIVIDER 1 – PHARMACOLOGY
// ══════════════════════════════════════════════════════════════════════════════
sectionSlide("SECTION 1", "Pharmacology of Local Anesthetics", 1);

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 4 – CLASSIFICATION
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("Classification of Local Anesthetics", C.navyMid);

  // ESTERS box
  sl.addShape(pres.shapes.RECTANGLE, {
    x: 0.2, y: 0.9, w: 4.5, h: 4.3,
    fill: { color: "FFF3E0" }, line: { color: C.orange, pt: 2 }
  });
  sl.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 0.9, w: 4.5, h: 0.55, fill: { color: C.orange }, line: { color: C.orange } });
  sl.addText("ESTERS", { x: 0.2, y: 0.9, w: 4.5, h: 0.55, fontSize: 18, bold: true, color: C.white, align: "center", valign: "middle", charSpacing: 3 });

  const esters = [
    ["Metabolism:", "Plasma cholinesterase"],
    ["Examples:", "Procaine, Tetracaine\nBenzocaine, Cocaine"],
    ["Memory aid:", "One 'i' in 'ester'"],
    ["Allergy:", "Para-amino benzoic acid (PABA)\n→ can cross-react within class"],
    ["Key point:", "Avoid in pseudocholinesterase\ndeficiency"],
  ];
  esters.forEach(([label, val], i) => {
    sl.addText([
      { text: label + " ", options: { bold: true, color: C.orange } },
      { text: val, options: { color: "5D4037" } }
    ], { x: 0.35, y: 1.52 + i * 0.58, w: 4.2, h: 0.55, fontSize: 12.5, fontFace: "Calibri" });
  });

  // AMIDES box
  sl.addShape(pres.shapes.RECTANGLE, {
    x: 5.1, y: 0.9, w: 4.7, h: 4.3,
    fill: { color: "E8F4FB" }, line: { color: C.navyMid, pt: 2 }
  });
  sl.addShape(pres.shapes.RECTANGLE, { x: 5.1, y: 0.9, w: 4.7, h: 0.55, fill: { color: C.navyMid }, line: { color: C.navyMid } });
  sl.addText("AMIDES", { x: 5.1, y: 0.9, w: 4.7, h: 0.55, fontSize: 18, bold: true, color: C.white, align: "center", valign: "middle", charSpacing: 3 });

  const amides = [
    ["Metabolism:", "Hepatic microsomal enzymes"],
    ["Examples:", "Lidocaine, Bupivacaine\nRopivacaine, Mepivacaine\nPrilocaine"],
    ["Memory aid:", "Two 'i's in the drug name\n(lidocaine → li-i, bupivacaine → i-i)"],
    ["Allergy:", "Extremely rare — most reactions\nare vasovagal or epi effects"],
    ["Key point:", "No cross-reactivity with esters\nPreferred in liver disease? Caution!"],
  ];
  amides.forEach(([label, val], i) => {
    sl.addText([
      { text: label + " ", options: { bold: true, color: C.navyMid } },
      { text: val, options: { color: "1A3A5C" } }
    ], { x: 5.25, y: 1.52 + i * 0.58, w: 4.4, h: 0.55, fontSize: 12.5, fontFace: "Calibri" });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 5 – MECHANISM OF ACTION
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("Mechanism of Action", C.navyMid);

  // Main mechanism box
  sl.addShape(pres.shapes.RECTANGLE, {
    x: 0.2, y: 0.85, w: 9.6, h: 0.75,
    fill: { color: C.navyLight }, line: { color: C.navyLight }
  });
  sl.addText("Reversible blockade of voltage-gated Na⁺ channels → prevents depolarization → no action potential", {
    x: 0.3, y: 0.85, w: 9.4, h: 0.75,
    fontSize: 14, bold: true, color: C.gold, align: "center", valign: "middle", fontFace: "Calibri"
  });

  // Differential block heading
  sl.addText("Order of Nerve Fiber Blockade (smallest → largest):", {
    x: 0.2, y: 1.75, w: 9.6, h: 0.35, fontSize: 13, bold: true, color: C.navyMid, fontFace: "Calibri"
  });

  const fibers = [
    { fiber: "C fibers (unmyelinated)", function: "Pain, Temperature", order: "1st — FIRST blocked", color: C.red },
    { fiber: "A-delta fibers", function: "Fast pain, Cold", order: "2nd", color: C.orange },
    { fiber: "A-beta fibers", function: "Touch, Pressure", order: "3rd", color: C.teal },
    { fiber: "A-alpha fibers (motor)", function: "Motor function", order: "4th — LAST blocked", color: C.navyMid },
  ];

  fibers.forEach((f, i) => {
    const y = 2.18 + i * 0.72;
    sl.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 0.55, h: 0.55, fill: { color: f.color }, line: { color: f.color } });
    sl.addText(String(i + 1), { x: 0.2, y, w: 0.55, h: 0.55, fontSize: 16, bold: true, color: C.white, align: "center", valign: "middle" });
    sl.addShape(pres.shapes.RECTANGLE, { x: 0.85, y, w: 9.0, h: 0.55, fill: { color: "F0F5FA" }, line: { color: "D8E8F0" } });
    sl.addText([
      { text: f.fiber + " — ", options: { bold: true, color: f.color } },
      { text: f.function + "  ", options: { color: C.navyMid } },
      { text: "(" + f.order + ")", options: { bold: true, color: "666666", fontSize: 11 } }
    ], { x: 1.0, y, w: 8.65, h: 0.55, fontSize: 13, fontFace: "Calibri", valign: "middle" });
  });

  // Clinical pearl
  sl.addShape(pres.shapes.ROUNDED_RECTANGLE, {
    x: 0.2, y: 5.0, w: 9.6, h: 0.42,
    fill: { color: "FFF9E6" }, line: { color: C.gold, pt: 1 }, rectRadius: 0.06
  });
  sl.addText("⭐  Clinical Pearl: Patients feel pressure/touch but NOT pain during adequate LA — explain this to reassure them!", {
    x: 0.3, y: 5.0, w: 9.4, h: 0.42, fontSize: 12, color: "7D6608", fontFace: "Calibri", valign: "middle"
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 6 – PHARMACOKINETICS
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("Key Pharmacokinetic Properties", C.navyMid);

  const props = [
    {
      prop: "pKa", determines: "Speed of Onset",
      detail: "Lower pKa → more drug in non-ionized form at pH 7.4 → faster membrane crossing → faster onset\nLidocaine pKa 7.9 (fast)  |  Bupivacaine pKa 8.1 (slower)",
      color: C.red
    },
    {
      prop: "Protein Binding", determines: "Duration of Action",
      detail: "Higher protein binding → longer receptor affinity → longer duration\nLidocaine ~65% bound (30–60 min)  |  Bupivacaine >95% bound (4–8 hrs)",
      color: C.teal
    },
    {
      prop: "Lipid Solubility", determines: "Potency",
      detail: "Higher lipid solubility → better membrane penetration → more potent\nBupivacaine most lipid soluble → most potent & most cardiotoxic",
      color: C.orange
    },
  ];

  props.forEach((p, i) => {
    const y = 0.9 + i * 1.48;
    sl.addShape(pres.shapes.RECTANGLE, {
      x: 0.2, y, w: 9.6, h: 1.3,
      fill: { color: "F2F8FC" }, line: { color: p.color, pt: 1.5 }
    });
    sl.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 0.12, h: 1.3, fill: { color: p.color }, line: { color: p.color } });
    sl.addText(p.prop, { x: 0.45, y: y + 0.08, w: 2.5, h: 0.4, fontSize: 15, bold: true, color: p.color, fontFace: "Calibri" });
    sl.addText("→  " + p.determines, { x: 2.8, y: y + 0.08, w: 6.8, h: 0.4, fontSize: 13, bold: true, color: C.navyMid, fontFace: "Calibri" });
    sl.addText(p.detail, { x: 0.45, y: y + 0.5, w: 9.2, h: 0.72, fontSize: 11.5, color: "2C3E50", fontFace: "Calibri" });
  });

  // Infected tissue pearl
  sl.addShape(pres.shapes.ROUNDED_RECTANGLE, {
    x: 0.2, y: 5.0, w: 9.6, h: 0.42,
    fill: { color: "FDECEA" }, line: { color: C.red, pt: 1 }, rectRadius: 0.06
  });
  sl.addText("🔴  Why LA fails in abscesses: Infected tissue pH is acidic → more drug ionized → can't cross membrane → poor block. Inject around the infection, not into it!", {
    x: 0.3, y: 5.0, w: 9.4, h: 0.42, fontSize: 11.5, color: "7B241C", fontFace: "Calibri", valign: "middle"
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 7 – DOSING TABLE
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("ED Drug Reference: Dosing Guide", C.navyMid);

  const headers = [
    { text: "Agent", options: { bold: true, color: C.white, fill: { color: C.navyMid } } },
    { text: "Class", options: { bold: true, color: C.white, fill: { color: C.navyMid } } },
    { text: "Onset", options: { bold: true, color: C.white, fill: { color: C.navyMid } } },
    { text: "Duration (plain)", options: { bold: true, color: C.white, fill: { color: C.navyMid } } },
    { text: "Max Dose (plain)", options: { bold: true, color: C.white, fill: { color: C.navyMid } } },
    { text: "Max Dose (+Epi)", options: { bold: true, color: C.white, fill: { color: C.navyMid } } },
  ];

  const rows = [
    ["Lidocaine 1-2%", "Amide", "Fast (2-5 min)", "30-60 min", "4.5 mg/kg (300 mg)", "7 mg/kg (500 mg)"],
    ["Bupivacaine 0.25-0.5%", "Amide", "Slow (5-10 min)", "4-8 hours", "2.5 mg/kg (175 mg)", "3 mg/kg (225 mg)"],
    ["Ropivacaine 0.2-0.75%", "Amide", "Intermediate", "3-8 hours", "3 mg/kg", "3 mg/kg"],
    ["Procaine 1-2%", "Ester", "Slow", "15-30 min", "600 mg", "—"],
  ];

  const rowColors = ["FFFFFF", "EBF5FB", "FFFFFF", "EBF5FB"];

  const tableData = [
    headers.map(h => ({ text: h.text, options: { bold: true, color: C.white, fill: { color: C.navyMid }, fontSize: 12 } })),
    ...rows.map((r, ri) =>
      r.map(cell => ({ text: cell, options: { color: "2C3E50", fill: { color: rowColors[ri] }, fontSize: 11.5 } }))
    ),
  ];

  sl.addTable(tableData, {
    x: 0.15, y: 0.85, w: 9.7,
    border: { pt: 0.5, color: "D0D8E0" },
    rowH: 0.65,
    colW: [2.2, 1.0, 1.3, 1.5, 2.0, 1.7],
  });

  // Calculation box
  sl.addShape(pres.shapes.ROUNDED_RECTANGLE, {
    x: 0.15, y: 4.3, w: 9.7, h: 1.08,
    fill: { color: C.navyLight }, line: { color: C.teal, pt: 1.5 }, rectRadius: 0.08
  });
  sl.addText([
    { text: "⚡ HOW TO CALCULATE: ", options: { bold: true, color: C.gold, fontSize: 13 } },
    { text: "1% = 10 mg/mL  |  2% = 20 mg/mL\n", options: { color: C.textLight, fontSize: 12 } },
    { text: "Example: ", options: { bold: true, color: C.teal, fontSize: 12 } },
    { text: "70 kg patient, lidocaine plain: 4.5 × 70 = 315 mg ÷ 10 mg/mL = 31.5 mL of 1% lidocaine (max dose)", options: { color: C.textLight, fontSize: 12 } },
  ], { x: 0.3, y: 4.32, w: 9.45, h: 1.04, fontFace: "Calibri", valign: "middle" });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 8 – EPINEPHRINE
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("Role of Epinephrine in Local Anesthetics", C.navyMid);

  // Benefits
  sl.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 0.88, w: 4.5, h: 0.42, fill: { color: C.teal }, line: { color: C.teal } });
  sl.addText("✅  BENEFITS of Adding Epinephrine", { x: 0.2, y: 0.88, w: 4.5, h: 0.42, fontSize: 13, bold: true, color: C.white, align: "center", valign: "middle" });

  const benefits = [
    "Local vasoconstriction → slows systemic absorption",
    "Prolongs duration of action (up to 2×)",
    "Allows higher total dose of LA",
    "Reduces bleeding → improves visualization",
    "Concentration used: 1:100,000 or 1:200,000",
  ];
  sl.addText(benefits.map(b => ({ text: "• " + b, options: { bullet: false, breakLine: true, color: "1A5276" } })),
    { x: 0.25, y: 1.38, w: 4.4, h: 2.6, fontSize: 12.5, fontFace: "Calibri" });

  // Contraindications
  sl.addShape(pres.shapes.RECTANGLE, { x: 5.1, y: 0.88, w: 4.7, h: 0.42, fill: { color: C.red }, line: { color: C.red } });
  sl.addText("🚫  CONTRAINDICATIONS (Classic 5)", { x: 5.1, y: 0.88, w: 4.7, h: 0.42, fontSize: 13, bold: true, color: C.white, align: "center", valign: "middle" });

  const contra = [
    ["Digits", "Fingers & toes — risk of ischemia"],
    ["Penis", "Dorsal nerve block"],
    ["Nose tip / Ala", "End-artery supply"],
    ["Earlobes", "End-artery supply"],
    ["Infected wounds", "Reduces blood flow → ↑ infection risk"],
  ];
  contra.forEach(([site, reason], i) => {
    const y = 1.38 + i * 0.54;
    sl.addShape(pres.shapes.RECTANGLE, {
      x: 5.1, y, w: 4.7, h: 0.48,
      fill: { color: i % 2 === 0 ? "FDECEA" : "FADBD8" }, line: { color: "F5B7B1" }
    });
    sl.addText([
      { text: "⛔ " + site + ": ", options: { bold: true, color: C.red } },
      { text: reason, options: { color: "641E16" } }
    ], { x: 5.18, y: y + 0.04, w: 4.5, h: 0.4, fontSize: 12, fontFace: "Calibri", valign: "middle" });
  });

  // Additional cautions
  sl.addShape(pres.shapes.ROUNDED_RECTANGLE, {
    x: 0.2, y: 4.12, w: 9.6, h: 0.42,
    fill: { color: "FFF9E6" }, line: { color: C.gold, pt: 1 }, rectRadius: 0.06
  });
  sl.addText("⚠️  Additional caution: Peripheral vascular disease | Uncontrolled HTN | Thyrotoxicosis | MAO inhibitor use",
    { x: 0.3, y: 4.12, w: 9.4, h: 0.42, fontSize: 12, color: "7D6608", fontFace: "Calibri", valign: "middle" });

  sl.addShape(pres.shapes.ROUNDED_RECTANGLE, {
    x: 0.2, y: 4.65, w: 9.6, h: 0.75,
    fill: { color: "E8F8F5" }, line: { color: C.teal, pt: 1 }, rectRadius: 0.06
  });
  sl.addText([
    { text: "📌 NOTE: ", options: { bold: true, color: C.teal } },
    { text: "Recent evidence (Denkler meta-analysis) shows epinephrine is SAFE in fingers in healthy patients without vascular disease. The 'never use epi in digits' teaching is largely outdated, but we still avoid it in patients with documented vascular compromise.", options: { color: "1A5276" } }
  ], { x: 0.3, y: 4.67, w: 9.4, h: 0.71, fontSize: 11.5, fontFace: "Calibri", valign: "middle" });
}

// ══════════════════════════════════════════════════════════════════════════════
// SECTION DIVIDER 2 – LAST
// ══════════════════════════════════════════════════════════════════════════════
sectionSlide("SECTION 2", "Local Anesthetic Systemic Toxicity (LAST)", 2);

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 9 – LAST OVERVIEW & RISK FACTORS
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("LAST: Overview & Risk Factors", C.red);

  sl.addText("Cause: Excessive plasma LA concentration from accidental intravascular injection, overdose, or rapid absorption", {
    x: 0.2, y: 0.88, w: 9.6, h: 0.5, fontSize: 13, color: "7B241C", fontFace: "Calibri",
    fill: { color: "FDECEA" }
  });

  // Absorption risk (left)
  sl.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 1.5, w: 4.5, h: 0.42, fill: { color: C.orange }, line: { color: C.orange } });
  sl.addText("Absorption Risk (Highest → Lowest)", { x: 0.2, y: 1.5, w: 4.5, h: 0.42, fontSize: 12.5, bold: true, color: C.white, align: "center", valign: "middle" });

  const absorption = ["Intercostal > Caudal epidural", "Lumbar epidural > Brachial plexus", "Femoral > Subcutaneous"];
  absorption.forEach((a, i) => {
    sl.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 2.0 + i * 0.5, w: 4.5, h: 0.44, fill: { color: i % 2 === 0 ? "FEF9E7" : "FDF2E9" }, line: { color: "F0D9A8" } });
    sl.addText("• " + a, { x: 0.35, y: 2.0 + i * 0.5, w: 4.2, h: 0.44, fontSize: 12.5, color: "784212", fontFace: "Calibri", valign: "middle" });
  });

  // Risk factors (right)
  sl.addShape(pres.shapes.RECTANGLE, { x: 5.1, y: 1.5, w: 4.7, h: 0.42, fill: { color: C.red }, line: { color: C.red } });
  sl.addText("Patient Risk Factors", { x: 5.1, y: 1.5, w: 4.7, h: 0.42, fontSize: 12.5, bold: true, color: C.white, align: "center", valign: "middle" });

  const risks = [
    "Extremes of age (elderly, neonates)",
    "Low lean body mass / cachexia",
    "Hepatic dysfunction (amides)",
    "Pre-existing cardiac disease",
    "Metabolic acidosis",
    "High-volume fascial plane blocks",
  ];
  risks.forEach((r, i) => {
    sl.addShape(pres.shapes.RECTANGLE, { x: 5.1, y: 2.0 + i * 0.46, w: 4.7, h: 0.4, fill: { color: i % 2 === 0 ? "FDECEA" : "FADBD8" }, line: { color: "F5B7B1" } });
    sl.addText("• " + r, { x: 5.25, y: 2.0 + i * 0.46, w: 4.4, h: 0.4, fontSize: 12, color: "641E16", fontFace: "Calibri", valign: "middle" });
  });

  sl.addShape(pres.shapes.ROUNDED_RECTANGLE, {
    x: 0.2, y: 4.9, w: 9.6, h: 0.48,
    fill: { color: "FDECEA" }, line: { color: C.red, pt: 1.5 }, rectRadius: 0.06
  });
  sl.addText("🔴  Bupivacaine is the MOST DANGEROUS agent — can cause cardiac arrest with minimal preceding CNS symptoms due to high lipid solubility", {
    x: 0.3, y: 4.9, w: 9.4, h: 0.48, fontSize: 12, bold: true, color: "7B241C", fontFace: "Calibri", valign: "middle"
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 10 – LAST CLINICAL PROGRESSION
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("LAST: Clinical Progression", C.red);

  sl.addText("CNS symptoms PRECEDE cardiovascular symptoms (CNS has lower threshold)", {
    x: 0.2, y: 0.85, w: 9.6, h: 0.38, fontSize: 13, bold: true, color: C.navyMid, fontFace: "Calibri", align: "center"
  });

  const stages = [
    {
      label: "MILD — CNS Excitation", color: C.teal,
      items: ["Circumoral numbness / tingling", "Metallic taste", "Tinnitus, light-headedness", "Restlessness, agitation"]
    },
    {
      label: "MODERATE — CNS Depression", color: C.orange,
      items: ["Slurred speech", "Drowsiness", "Muscle twitching / tremors"]
    },
    {
      label: "SEVERE — Neurological", color: C.red,
      items: ["Generalised tonic-clonic seizures", "Loss of consciousness", "Respiratory arrest"]
    },
    {
      label: "CARDIOVASCULAR COLLAPSE ⚠️", color: "8E0000",
      items: ["Bradycardia, conduction block", "Widened QRS, VT / VF", "Asystole — CARDIAC ARREST"]
    },
  ];

  stages.forEach((s, i) => {
    const x = i < 2 ? 0.15 : 5.1;
    const y = i < 2 ? (0.9 + (i % 2) * 2.05) : (0.9 + (i % 2) * 2.05);
    const adjustedY = i === 0 ? 1.35 : i === 1 ? 3.45 : i === 2 ? 1.35 : 3.45;
    const adjustedX = i < 2 ? 0.15 : 5.15;
    sl.addShape(pres.shapes.RECTANGLE, {
      x: adjustedX, y: adjustedY, w: 4.75, h: 1.85,
      fill: { color: "F8F9FA" }, line: { color: s.color, pt: 2 }
    });
    sl.addShape(pres.shapes.RECTANGLE, { x: adjustedX, y: adjustedY, w: 4.75, h: 0.4, fill: { color: s.color }, line: { color: s.color } });
    sl.addText(s.label, { x: adjustedX + 0.1, y: adjustedY, w: 4.55, h: 0.4, fontSize: 12, bold: true, color: C.white, valign: "middle", fontFace: "Calibri" });
    s.items.forEach((item, j) => {
      sl.addText("▸ " + item, {
        x: adjustedX + 0.15, y: adjustedY + 0.47 + j * 0.37, w: 4.5, h: 0.35,
        fontSize: 12, color: "2C3E50", fontFace: "Calibri"
      });
    });
  });

  // Arrow
  sl.addShape(pres.shapes.DOWN_ARROW, { x: 4.62, y: 1.85, w: 0.55, h: 3.0, fill: { color: C.red }, line: { color: C.red } });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 11 – LAST MANAGEMENT
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("LAST: Management Protocol", C.red);

  // Red alert banner
  sl.addShape(pres.shapes.RECTANGLE, { x: 0.15, y: 0.82, w: 9.7, h: 0.5, fill: { color: C.red }, line: { color: C.red } });
  sl.addText("STOP injecting  |  Call for help  |  Secure AIRWAY  |  100% O₂  |  IV access", {
    x: 0.15, y: 0.82, w: 9.7, h: 0.5, fontSize: 13.5, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri"
  });

  const steps = [
    {
      num: "1", title: "SEIZURES", color: C.orange,
      lines: ["Benzodiazepines FIRST: Midazolam 0.05–0.1 mg/kg IV  OR  Lorazepam 0.05 mg/kg IV",
        "Refractory: Propofol (small dose) — NOTE: Propofol has lipid vehicle but is NOT a substitute for ILE",
        "Avoid succinylcholine (masks ongoing EEG seizure activity)"]
    },
    {
      num: "2", title: "CARDIAC ARREST", color: "8E0000",
      lines: ["Standard CPR / ACLS",
        "Epinephrine: Use SMALL doses 10–100 mcg IV (NOT the standard 1 mg — worsens outcomes in LAST)",
        "AVOID: Vasopressin | CCBs | Beta-blockers | Lidocaine as antiarrhythmic"]
    },
    {
      num: "3", title: "INTRALIPID 20% — THE ANTIDOTE", color: C.teal,
      lines: ["Bolus: 1.5 mL/kg IV over 1 min (~100 mL for 70 kg patient)",
        "Infusion: 0.25 mL/kg/min × ≥10 min after hemodynamic stability",
        "Repeat bolus if arrest persists | Max ~10 mL/kg over 30 min",
        "Mechanism: 'Lipid sink' — sequesters lipid-soluble LA away from heart & brain"]
    },
  ];

  steps.forEach((s, i) => {
    const y = 1.42 + i * 1.35;
    sl.addShape(pres.shapes.ELLIPSE, { x: 0.15, y: y + 0.05, w: 0.5, h: 0.5, fill: { color: s.color }, line: { color: s.color } });
    sl.addText(s.num, { x: 0.15, y: y + 0.05, w: 0.5, h: 0.5, fontSize: 16, bold: true, color: C.white, align: "center", valign: "middle" });
    sl.addText("STEP " + s.num + ": " + s.title, { x: 0.75, y, w: 9.0, h: 0.38, fontSize: 13, bold: true, color: s.color, fontFace: "Calibri" });
    sl.addText(s.lines.map(l => "• " + l).join("\n"), {
      x: 0.75, y: y + 0.38, w: 9.0, h: 0.95, fontSize: 11.5, color: "2C3E50", fontFace: "Calibri"
    });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SECTION DIVIDER 3 – TECHNIQUES
// ══════════════════════════════════════════════════════════════════════════════
sectionSlide("SECTION 3", "Techniques in the Emergency Department", 3);

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 12 – ROUTES OVERVIEW
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("Routes of Local Anesthesia in the ED", C.navyMid);

  const routes = [
    {
      title: "1. TOPICAL", color: C.teal, x: 0.2, y: 0.88,
      desc: "No injection needed\n\n• Intact skin: EMLA, LMX 4%\n• Open wounds: LET gel\n• Mucosa: Viscous lidocaine,\n  Benzocaine spray\n\nIdeal for: Pediatric patients,\nIV access, airway procedures"
    },
    {
      title: "2. LOCAL INFILTRATION", color: C.orange, x: 3.55, y: 0.88,
      desc: "Injection into tissue\n\n• Direct wound infiltration\n• Field block (ring of LA\n  around the area)\n\nIdeal for: Laceration repair,\nsimple abscess, minor procedures"
    },
    {
      title: "3. REGIONAL / NERVE BLOCK", color: C.navyMid, x: 6.9, y: 0.88,
      desc: "Block proximal nerve trunk\n\n• Peripheral nerve blocks\n• Hematoma block\n• IV Regional (Bier block)\n\nIdeal for: Fractures, complex\nwound repair, limb procedures"
    },
  ];

  routes.forEach(r => {
    sl.addShape(pres.shapes.RECTANGLE, {
      x: r.x, y: r.y, w: 3.15, h: 4.45,
      fill: { color: "F7FBFF" }, line: { color: r.color, pt: 2 },
      shadow: { type: "outer", color: "000000", blur: 6, offset: 2, angle: 135, opacity: 0.15 }
    });
    sl.addShape(pres.shapes.RECTANGLE, { x: r.x, y: r.y, w: 3.15, h: 0.5, fill: { color: r.color }, line: { color: r.color } });
    sl.addText(r.title, { x: r.x, y: r.y, w: 3.15, h: 0.5, fontSize: 13, bold: true, color: C.white, align: "center", valign: "middle", charSpacing: 2 });
    sl.addText(r.desc, { x: r.x + 0.12, y: r.y + 0.58, w: 2.88, h: 3.8, fontSize: 12, color: "1A3A5C", fontFace: "Calibri" });
  });

  sl.addShape(pres.shapes.ROUNDED_RECTANGLE, {
    x: 0.2, y: 5.05, w: 9.6, h: 0.38,
    fill: { color: "FFF9E6" }, line: { color: C.gold, pt: 1 }, rectRadius: 0.06
  });
  sl.addText("⭐  Pearl: Nerve blocks use LESS drug, cause LESS tissue distortion, and provide SUPERIOR analgesia compared to local infiltration for the same area.", {
    x: 0.3, y: 5.05, w: 9.4, h: 0.38, fontSize: 11.5, color: "7D6608", fontFace: "Calibri", valign: "middle"
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 13 – TOPICAL AGENTS
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("Topical Anesthetic Agents", C.teal);

  const tData = [
    [
      { text: "Agent", options: { bold: true, color: C.white, fill: { color: C.navyMid } } },
      { text: "Active Ingredients", options: { bold: true, color: C.white, fill: { color: C.navyMid } } },
      { text: "Use in ED", options: { bold: true, color: C.white, fill: { color: C.navyMid } } },
      { text: "Time to Effect", options: { bold: true, color: C.white, fill: { color: C.navyMid } } },
    ],
    [
      { text: "EMLA®", options: { fill: { color: "E8F4FB" }, bold: true, color: C.navyMid } },
      { text: "Lidocaine 2.5% + Prilocaine 2.5%", options: { fill: { color: "E8F4FB" }, color: "2C3E50" } },
      { text: "IV access, minor procedures (intact skin)", options: { fill: { color: "E8F4FB" }, color: "2C3E50" } },
      { text: "60 min", options: { fill: { color: "E8F4FB" }, bold: true, color: C.orange } },
    ],
    [
      { text: "LMX 4%", options: { fill: { color: "FFFFFF" }, bold: true, color: C.navyMid } },
      { text: "Liposomal Lidocaine 4%", options: { fill: { color: "FFFFFF" }, color: "2C3E50" } },
      { text: "Venipuncture, paediatric IV access", options: { fill: { color: "FFFFFF" }, color: "2C3E50" } },
      { text: "30–60 min", options: { fill: { color: "FFFFFF" }, bold: true, color: C.orange } },
    ],
    [
      { text: "LET Gel ⭐", options: { fill: { color: "E8F4FB" }, bold: true, color: C.teal } },
      { text: "Lidocaine 4% + Epi 0.1% + Tetracaine 0.5%", options: { fill: { color: "E8F4FB" }, color: "2C3E50" } },
      { text: "Paediatric facial/scalp lacerations", options: { fill: { color: "E8F4FB" }, color: "2C3E50" } },
      { text: "20–30 min", options: { fill: { color: "E8F4FB" }, bold: true, color: C.teal } },
    ],
    [
      { text: "Viscous Lidocaine 2%", options: { fill: { color: "FFFFFF" }, bold: true, color: C.navyMid } },
      { text: "Lidocaine 2%", options: { fill: { color: "FFFFFF" }, color: "2C3E50" } },
      { text: "NG tube, bronchoscopy, upper airway", options: { fill: { color: "FFFFFF" }, color: "2C3E50" } },
      { text: "2–5 min", options: { fill: { color: "FFFFFF" }, bold: true, color: C.teal } },
    ],
    [
      { text: "Benzocaine 20%", options: { fill: { color: "E8F4FB" }, bold: true, color: C.navyMid } },
      { text: "Benzocaine 20% spray", options: { fill: { color: "E8F4FB" }, color: "2C3E50" } },
      { text: "Oral mucosa, airway topicalisation", options: { fill: { color: "E8F4FB" }, color: "2C3E50" } },
      { text: "15–30 sec", options: { fill: { color: "E8F4FB" }, bold: true, color: C.teal } },
    ],
  ];

  sl.addTable(tData, {
    x: 0.15, y: 0.85, w: 9.7,
    border: { pt: 0.5, color: "D0D8E0" },
    rowH: 0.62,
    colW: [1.7, 2.8, 2.8, 1.4],
  });

  sl.addShape(pres.shapes.ROUNDED_RECTANGLE, {
    x: 0.15, y: 4.88, w: 9.7, h: 0.55,
    fill: { color: "FDECEA" }, line: { color: C.red, pt: 1 }, rectRadius: 0.06
  });
  sl.addText([
    { text: "⚠️  METHEMOGLOBINEMIA WARNING: ", options: { bold: true, color: C.red } },
    { text: "Benzocaine AND prilocaine (in EMLA) can cause methemoglobinemia. Risk is highest in infants. Suspect if cyanosis persists despite O₂. Treat with Methylene Blue 1–2 mg/kg IV.", options: { color: "7B241C" } }
  ], { x: 0.25, y: 4.9, w: 9.5, h: 0.52, fontSize: 11.5, fontFace: "Calibri", valign: "middle" });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 14 – INFILTRATION TECHNIQUE & PAIN REDUCTION
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("Local Infiltration: Technique & Minimising Pain", C.navyMid);

  // Left: technique
  sl.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 0.88, w: 4.55, h: 0.42, fill: { color: C.navyMid }, line: { color: C.navyMid } });
  sl.addText("Infiltration Technique", { x: 0.2, y: 0.88, w: 4.55, h: 0.42, fontSize: 13, bold: true, color: C.white, align: "center", valign: "middle" });

  const techSteps = [
    ["1.", "Draw up LA, aspirate before injecting"],
    ["2.", "Insert needle at wound margin (not through intact skin)"],
    ["3.", "Advance in already-anesthetised tissue"],
    ["4.", "Inject slowly — 1 mL per 10 seconds"],
    ["5.", "Fan technique for larger areas"],
    ["6.", "Never inject into infected tissue"],
  ];

  techSteps.forEach(([num, step], i) => {
    const y = 1.38 + i * 0.55;
    sl.addShape(pres.shapes.ELLIPSE, { x: 0.22, y: y + 0.04, w: 0.38, h: 0.38, fill: { color: C.teal }, line: { color: C.teal } });
    sl.addText(num, { x: 0.22, y: y + 0.04, w: 0.38, h: 0.38, fontSize: 11, bold: true, color: C.white, align: "center", valign: "middle" });
    sl.addText(step, { x: 0.7, y: y + 0.04, w: 4.0, h: 0.38, fontSize: 12, color: "1A3A5C", fontFace: "Calibri", valign: "middle" });
  });

  // Right: pain reduction
  sl.addShape(pres.shapes.RECTANGLE, { x: 5.0, y: 0.88, w: 4.8, h: 0.42, fill: { color: C.orange }, line: { color: C.orange } });
  sl.addText("Reducing Injection Pain (Evidence-Based)", { x: 5.0, y: 0.88, w: 4.8, h: 0.42, fontSize: 12, bold: true, color: C.white, align: "center", valign: "middle" });

  const painTips = [
    { tip: "Buffer with NaHCO₃", detail: "9 mL lido + 1 mL NaHCO₃ 8.4%\n→ raises pH → less sting + faster onset" },
    { tip: "Warm solution", detail: "Heat to body temp (37°C)\nbefore injection" },
    { tip: "Fine needle", detail: "25–30G needle, especially on face\n→ less tissue trauma" },
    { tip: "Slow injection", detail: "Rate matters more than needle size\n→ 1 mL / 10 seconds" },
    { tip: "Counter-stimulation", detail: "Gate control theory: pinch or\npressure nearby while injecting" },
  ];

  painTips.forEach((pt, i) => {
    const y = 1.38 + i * 0.72;
    sl.addShape(pres.shapes.RECTANGLE, { x: 5.0, y, w: 4.8, h: 0.66, fill: { color: i % 2 === 0 ? "FEF9E7" : "FDF2E9" }, line: { color: "F0D9A8" } });
    sl.addText([
      { text: pt.tip + ": ", options: { bold: true, color: C.orange } },
      { text: pt.detail, options: { color: "784212" } }
    ], { x: 5.12, y: y + 0.04, w: 4.55, h: 0.58, fontSize: 11.5, fontFace: "Calibri" });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 15 – NERVE BLOCKS IN ED
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("Key Nerve Blocks in the Emergency Department", C.navyMid);

  const blocks = [
    { block: "Digital nerve block", indication: "Finger/toe lac, nail bed, paronychia", approach: "Web space or volar approach", agent: "Lidocaine 1% (no epi)" },
    { block: "Median/Ulnar/Radial block (wrist)", indication: "Hand wounds, hand procedures", approach: "Anatomical landmark at wrist", agent: "Lidocaine 1% or Bupi 0.25%" },
    { block: "Femoral nerve block", indication: "Femoral # shaft, thigh pain", approach: "Below inguinal lig, lateral to femoral A", agent: "Bupivacaine 0.25%, 20–30 mL" },
    { block: "Fascia Iliaca Block (FICB)", indication: "Hip fracture (NOF #), femoral #", approach: "1 cm below inguinal lig, 2/3 lateral", agent: "Bupi 0.25%, 30–40 mL" },
    { block: "Hematoma block", indication: "Distal radius #, fracture reduction", approach: "Direct injection into hematoma", agent: "Lidocaine 1% (plain), 5–10 mL" },
    { block: "Infraorbital / Supraorbital", indication: "Forehead/cheek/lip laceration", approach: "Midpupillary line, orbital notch", agent: "Lidocaine 1%, 2–3 mL" },
    { block: "Posterior tibial nerve", indication: "Plantar foot procedures", approach: "Behind medial malleolus", agent: "Lidocaine 1%, 5 mL" },
    { block: "Intercostal nerve block", indication: "Rib fractures, thoracic pain", approach: "Below rib at posterior axillary line", agent: "Bupivacaine 0.25%, 3–5 mL" },
  ];

  const headers = [
    { text: "Block", options: { bold: true, color: C.white, fill: { color: C.navyLight } } },
    { text: "Indication", options: { bold: true, color: C.white, fill: { color: C.navyLight } } },
    { text: "Approach", options: { bold: true, color: C.white, fill: { color: C.navyLight } } },
    { text: "Agent / Volume", options: { bold: true, color: C.white, fill: { color: C.navyLight } } },
  ];

  const rowBg = ["F7FBFF", "EBF5FB", "F7FBFF", "EBF5FB", "F7FBFF", "EBF5FB", "F7FBFF", "EBF5FB"];

  const tableRows = blocks.map((b, i) => [
    { text: b.block, options: { bold: true, color: C.navyMid, fill: { color: rowBg[i] }, fontSize: 10.5 } },
    { text: b.indication, options: { color: "2C3E50", fill: { color: rowBg[i] }, fontSize: 10.5 } },
    { text: b.approach, options: { color: "2C3E50", fill: { color: rowBg[i] }, fontSize: 10.5 } },
    { text: b.agent, options: { color: C.teal, fill: { color: rowBg[i] }, fontSize: 10.5, bold: true } },
  ]);

  sl.addTable([headers, ...tableRows], {
    x: 0.15, y: 0.85, w: 9.7,
    border: { pt: 0.5, color: "D0D8E0" },
    rowH: 0.56,
    colW: [2.3, 2.4, 2.5, 2.5],
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 16 – FASCIA ILIACA BLOCK (DEEP DIVE)
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("Fascia Iliaca Block (FICB) — High-Yield ED Block", C.teal);

  // Why box
  sl.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 0.88, w: 9.6, h: 0.42, fill: { color: C.navyLight }, line: { color: C.navyLight } });
  sl.addText("WHY FICB in the ED? Hip/NOF fractures cause severe pain — opioids in elderly = delirium + respiratory depression. FICB provides equivalent or superior analgesia to IV morphine.", {
    x: 0.3, y: 0.88, w: 9.4, h: 0.42, fontSize: 12, color: C.textLight, fontFace: "Calibri", valign: "middle"
  });

  // Technique steps
  sl.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 1.4, w: 5.5, h: 0.38, fill: { color: C.teal }, line: { color: C.teal } });
  sl.addText("Landmark Technique (Step-by-Step)", { x: 0.2, y: 1.4, w: 5.5, h: 0.38, fontSize: 13, bold: true, color: C.white, align: "center", valign: "middle" });

  const steps = [
    "Draw a line from ASIS to Pubic Tubercle",
    "Find junction of LATERAL 1/3 and MEDIAL 2/3",
    "Mark a point 1 cm INFERIOR to this junction",
    "Clean with antiseptic, use 22G spinal needle",
    "Advance until 'double-pop' (fascia lata then fascia iliaca)",
    "Aspirate (confirm no blood), inject 30–40 mL bupivacaine 0.25%",
    "Wait 15–20 min for full effect",
  ];

  steps.forEach((step, i) => {
    const y = 1.88 + i * 0.48;
    sl.addShape(pres.shapes.ELLIPSE, { x: 0.22, y: y + 0.03, w: 0.38, h: 0.38, fill: { color: C.teal }, line: { color: C.teal } });
    sl.addText(String(i + 1), { x: 0.22, y: y + 0.03, w: 0.38, h: 0.38, fontSize: 10, bold: true, color: C.white, align: "center", valign: "middle" });
    sl.addText(step, { x: 0.7, y: y + 0.03, w: 4.9, h: 0.38, fontSize: 12, color: "1A3A5C", fontFace: "Calibri", valign: "middle" });
  });

  // Right: evidence + tips
  sl.addShape(pres.shapes.RECTANGLE, { x: 5.9, y: 1.4, w: 3.9, h: 0.38, fill: { color: C.navyMid }, line: { color: C.navyMid } });
  sl.addText("Evidence & Tips", { x: 5.9, y: 1.4, w: 3.9, h: 0.38, fontSize: 13, bold: true, color: C.white, align: "center", valign: "middle" });

  const evidenceTips = [
    "✅ 2025 scoping review (AJEM): EM physician-performed US-guided nerve blocks are safe & effective",
    "✅ Equivalent or superior to systemic opioids for NOF fracture",
    "✅ Reduces delirium, nausea, and respiratory depression in elderly",
    "💡 US guidance increases success rate & reduces complications",
    "💡 Can be done at bedside without anaesthesiology",
    "⚠️ Monitor for LAST (large volume block — 30–40 mL)",
  ];

  evidenceTips.forEach((tip, i) => {
    sl.addShape(pres.shapes.RECTANGLE, {
      x: 5.9, y: 1.88 + i * 0.52, w: 3.9, h: 0.46,
      fill: { color: i % 2 === 0 ? "E8F8F5" : "F0FAFA" }, line: { color: "A9DFBF" }
    });
    sl.addText(tip, { x: 6.0, y: 1.88 + i * 0.52, w: 3.7, h: 0.46, fontSize: 11, color: "1A5E20", fontFace: "Calibri", valign: "middle" });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 17 – HEMATOMA BLOCK
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("Hematoma Block — Distal Radius Fracture Reduction", C.navyMid);

  sl.addShape(pres.shapes.RECTANGLE, {
    x: 0.2, y: 0.88, w: 9.6, h: 0.5,
    fill: { color: "E8F4FB" }, line: { color: C.navyMid, pt: 1 }
  });
  sl.addText("Indication: Distal radius (Colles') fracture reduction | Closed fracture manipulation | Simple, single-operator, no special equipment needed", {
    x: 0.3, y: 0.88, w: 9.4, h: 0.5, fontSize: 12.5, color: C.navyMid, fontFace: "Calibri", valign: "middle"
  });

  // Steps (left)
  sl.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 1.48, w: 5.5, h: 0.38, fill: { color: C.navyMid }, line: { color: C.navyMid } });
  sl.addText("Technique", { x: 0.2, y: 1.48, w: 5.5, h: 0.38, fontSize: 13, bold: true, color: C.white, align: "center", valign: "middle" });

  const hSteps = [
    "Identify fracture site on X-ray",
    "Clean overlying skin with antiseptic",
    "Insert 21–23G needle perpendicular to fracture",
    "Aspirate — confirm blood (you're in hematoma!)",
    "Inject 5–10 mL lidocaine 1% plain (NO epinephrine)",
    "Wait 10–15 minutes for full anaesthesia",
    "Perform fracture reduction",
  ];

  hSteps.forEach((step, i) => {
    const y = 1.96 + i * 0.5;
    sl.addShape(pres.shapes.ROUNDED_RECTANGLE, {
      x: 0.2, y, w: 5.5, h: 0.44,
      fill: { color: i % 2 === 0 ? "EBF5FB" : "F7FBFF" }, line: { color: "AED6F1" }, rectRadius: 0.05
    });
    sl.addText([
      { text: String(i + 1) + ".  ", options: { bold: true, color: C.navyMid } },
      { text: step, options: { color: "1A3A5C" } }
    ], { x: 0.32, y, w: 5.28, h: 0.44, fontSize: 12.5, fontFace: "Calibri", valign: "middle" });
  });

  // Right: pros/cons
  sl.addShape(pres.shapes.RECTANGLE, { x: 5.9, y: 1.48, w: 3.9, h: 0.38, fill: { color: C.teal }, line: { color: C.teal } });
  sl.addText("Advantages & Cautions", { x: 5.9, y: 1.48, w: 3.9, h: 0.38, fontSize: 13, bold: true, color: C.white, align: "center", valign: "middle" });

  const pros = ["Simple — no special equipment", "Single-operator technique", "Effective (comparable to IV opioids)", "No sedation required", "Faster ED throughput"];
  const cons = ["Open fractures (contamination risk)", "Overlying skin infection", "Anticoagulated patients (relative CI)", "Confirm blood before injecting!"];

  sl.addText("✅  ADVANTAGES", { x: 5.92, y: 1.95, w: 3.8, h: 0.3, fontSize: 12, bold: true, color: C.teal });
  pros.forEach((p, i) => {
    sl.addText("• " + p, { x: 5.92, y: 2.28 + i * 0.35, w: 3.8, h: 0.32, fontSize: 11.5, color: "1A5E20", fontFace: "Calibri" });
  });

  sl.addText("❌  CONTRAINDICATIONS", { x: 5.92, y: 4.1, w: 3.8, h: 0.3, fontSize: 12, bold: true, color: C.red });
  cons.forEach((c, i) => {
    sl.addText("• " + c, { x: 5.92, y: 4.42 + i * 0.3, w: 3.8, h: 0.28, fontSize: 11.5, color: "7B241C", fontFace: "Calibri" });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SECTION DIVIDER 4 – SPECIAL TOPICS
// ══════════════════════════════════════════════════════════════════════════════
sectionSlide("SECTION 4", "Special Topics & Complications", 4);

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 18 – SPECIAL POPULATIONS
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("Special Populations", C.navyMid);

  const populations = [
    {
      title: "👶  PAEDIATRIC", color: C.teal,
      points: [
        "Always calculate weight-based dose in mg",
        "Max lidocaine: 4.5 mg/kg plain",
        "Topical LET for facial lacerations — NO NEEDLE",
        "EMLA for IV access (apply 45–60 min early)",
        "Reduce total dose proportionally with weight",
      ]
    },
    {
      title: "👴  ELDERLY", color: C.orange,
      points: [
        "Reduced protein binding → higher free drug levels",
        "Reduce total dose by 25–30%",
        "Prefer shorter-acting agents (lidocaine)",
        "FICB preferred over opioids for hip #",
        "Higher risk of LAST — aspirate carefully",
      ]
    },
    {
      title: "🤰  PREGNANT", color: C.navyMid,
      points: [
        "Lidocaine is safe (compatible with pregnancy)",
        "Avoid high-dose bupivacaine (cardiac risk)",
        "All LAs cross the placenta",
        "Higher risk of LAST (progesterone effect on Na+ channels)",
        "Seek anaesthesia input for large blocks",
      ]
    },
    {
      title: "🏥  HEPATIC DYSFUNCTION", color: C.red,
      points: [
        "Amides are hepatically metabolised",
        "Accumulate in liver disease → toxicity at lower doses",
        "Reduce amide doses significantly",
        "Consider ester alternatives (if available)",
        "Monitor closely post-injection",
      ]
    },
  ];

  populations.forEach((pop, i) => {
    const x = i % 2 === 0 ? 0.2 : 5.05;
    const y = i < 2 ? 0.88 : 3.2;
    sl.addShape(pres.shapes.RECTANGLE, {
      x, y, w: 4.65, h: 2.2,
      fill: { color: "F7FBFF" }, line: { color: pop.color, pt: 1.5 },
      shadow: { type: "outer", color: "000000", blur: 5, offset: 2, angle: 135, opacity: 0.12 }
    });
    sl.addShape(pres.shapes.RECTANGLE, { x, y, w: 4.65, h: 0.42, fill: { color: pop.color }, line: { color: pop.color } });
    sl.addText(pop.title, { x: x + 0.1, y, w: 4.45, h: 0.42, fontSize: 13, bold: true, color: C.white, valign: "middle", fontFace: "Calibri" });
    pop.points.forEach((pt, j) => {
      sl.addText("• " + pt, { x: x + 0.12, y: y + 0.5 + j * 0.32, w: 4.4, h: 0.3, fontSize: 11, color: "1A3A5C", fontFace: "Calibri" });
    });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 19 – METHEMOGLOBINEMIA
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("Methemoglobinemia from Local Anesthetics", C.red);

  // Causative agents
  sl.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 0.88, w: 9.6, h: 0.42, fill: { color: "FDECEA" }, line: { color: C.red, pt: 1 } });
  sl.addText("Causative agents: Benzocaine (highest risk) > Prilocaine > EMLA  |  Risk: Infants < 3 months most vulnerable", {
    x: 0.3, y: 0.88, w: 9.4, h: 0.42, fontSize: 12.5, bold: true, color: "7B241C", fontFace: "Calibri", align: "center", valign: "middle"
  });

  // Mechanism → Presentation → Treatment flow
  const boxes = [
    {
      title: "⚙️  MECHANISM", color: "8E0000",
      content: "Benzocaine/prilocaine oxidise Fe²⁺ (ferrous)\n→ Fe³⁺ (ferric) = METHEMOGLOBIN\n\nMetHb cannot carry O₂\n→ Functional anaemia despite normal Hb"
    },
    {
      title: "🔴  CLINICAL FEATURES", color: C.red,
      content: "• Cyanosis NOT responding to O₂\n• SpO₂ falsely reads ~85%\n  (co-oximetry needed for true SaO₂)\n• Chocolate-brown blood on sampling\n• Headache → Altered consciousness → Seizures\n• Symptoms when MetHb >1.5 g/dL"
    },
    {
      title: "💊  TREATMENT", color: C.teal,
      content: "1st: High-flow 100% O₂\n\nMethylene Blue 1–2 mg/kg IV over 5 min\n(Max dose: 7 mg/kg total)\n\nG6PD deficiency: AVOID methylene blue\n→ Use Ascorbic acid 1 g IV instead\n\nRepeat methylene blue if no response in 1 hr"
    },
  ];

  boxes.forEach((b, i) => {
    const x = 0.2 + i * 3.3;
    sl.addShape(pres.shapes.RECTANGLE, {
      x, y: 1.42, w: 3.1, h: 3.85,
      fill: { color: "F8F9FA" }, line: { color: b.color, pt: 2 },
      shadow: { type: "outer", color: "000000", blur: 6, offset: 2, angle: 135, opacity: 0.15 }
    });
    sl.addShape(pres.shapes.RECTANGLE, { x, y: 1.42, w: 3.1, h: 0.45, fill: { color: b.color }, line: { color: b.color } });
    sl.addText(b.title, { x: x + 0.1, y: 1.42, w: 2.9, h: 0.45, fontSize: 12.5, bold: true, color: C.white, valign: "middle" });
    sl.addText(b.content, { x: x + 0.12, y: 1.95, w: 2.9, h: 3.25, fontSize: 11.5, color: "2C3E50", fontFace: "Calibri" });
  });

  sl.addShape(pres.shapes.ROUNDED_RECTANGLE, {
    x: 0.2, y: 5.12, w: 9.6, h: 0.3,
    fill: { color: "FFF9E6" }, line: { color: C.gold, pt: 1 }, rectRadius: 0.05
  });
  sl.addText("⭐  Exam tip: 'Blue patient, SpO₂ 85%, not responding to O₂ after benzocaine spray' = Methemoglobinemia. Answer: Methylene blue.", {
    x: 0.3, y: 5.12, w: 9.4, h: 0.3, fontSize: 11, color: "7D6608", fontFace: "Calibri", valign: "middle"
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 20 – QUICK REFERENCE SUMMARY
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("Quick Reference: Right Drug for the Right Scenario", C.navyMid);

  const qrData = [
    [
      { text: "Clinical Scenario", options: { bold: true, color: C.white, fill: { color: C.navyLight } } },
      { text: "Agent of Choice", options: { bold: true, color: C.white, fill: { color: C.navyLight } } },
      { text: "Dose / Volume", options: { bold: true, color: C.white, fill: { color: C.navyLight } } },
    ],
    [
      { text: "Quick suture repair (< 1 hr)", options: { color: "1A3A5C", fill: { color: "EBF5FB" } } },
      { text: "Lidocaine 1% plain", options: { bold: true, color: C.teal, fill: { color: "EBF5FB" } } },
      { text: "4.5 mg/kg (max ~300 mg)", options: { color: "1A3A5C", fill: { color: "EBF5FB" } } },
    ],
    [
      { text: "Post-procedure analgesia needed", options: { color: "1A3A5C", fill: { color: "FFFFFF" } } },
      { text: "Bupivacaine 0.25%", options: { bold: true, color: C.teal, fill: { color: "FFFFFF" } } },
      { text: "2.5 mg/kg (max ~175 mg)", options: { color: "1A3A5C", fill: { color: "FFFFFF" } } },
    ],
    [
      { text: "Vascular area, need higher dose", options: { color: "1A3A5C", fill: { color: "EBF5FB" } } },
      { text: "Lidocaine 1% + Epi 1:100,000", options: { bold: true, color: C.teal, fill: { color: "EBF5FB" } } },
      { text: "7 mg/kg (max ~500 mg)", options: { color: "1A3A5C", fill: { color: "EBF5FB" } } },
    ],
    [
      { text: "Paediatric facial laceration", options: { color: "1A3A5C", fill: { color: "FFFFFF" } } },
      { text: "LET topical gel", options: { bold: true, color: C.teal, fill: { color: "FFFFFF" } } },
      { text: "3–5 mL on gauze, 20–30 min", options: { color: "1A3A5C", fill: { color: "FFFFFF" } } },
    ],
    [
      { text: "Hip/NOF # (elderly)", options: { color: "1A3A5C", fill: { color: "EBF5FB" } } },
      { text: "FICB (Bupivacaine 0.25%)", options: { bold: true, color: C.teal, fill: { color: "EBF5FB" } } },
      { text: "30–40 mL landmark technique", options: { color: "1A3A5C", fill: { color: "EBF5FB" } } },
    ],
    [
      { text: "Distal radius # reduction", options: { color: "1A3A5C", fill: { color: "FFFFFF" } } },
      { text: "Hematoma block (Lido 1%)", options: { bold: true, color: C.teal, fill: { color: "FFFFFF" } } },
      { text: "5–10 mL into fracture hematoma", options: { color: "1A3A5C", fill: { color: "FFFFFF" } } },
    ],
    [
      { text: "LAST with cardiac arrest", options: { bold: true, color: C.red, fill: { color: "FDECEA" } } },
      { text: "20% Lipid Emulsion (Intralipid)", options: { bold: true, color: C.red, fill: { color: "FDECEA" } } },
      { text: "1.5 mL/kg bolus → 0.25 mL/kg/min", options: { bold: true, color: C.red, fill: { color: "FDECEA" } } },
    ],
    [
      { text: "MetHb after benzocaine (SpO₂ 85%)", options: { bold: true, color: "7B241C", fill: { color: "FADBD8" } } },
      { text: "Methylene Blue", options: { bold: true, color: "7B241C", fill: { color: "FADBD8" } } },
      { text: "1–2 mg/kg IV over 5 min", options: { bold: true, color: "7B241C", fill: { color: "FADBD8" } } },
    ],
  ];

  sl.addTable(qrData, {
    x: 0.15, y: 0.85, w: 9.7,
    border: { pt: 0.5, color: "D0D8E0" },
    rowH: 0.5,
    colW: [3.3, 3.3, 3.1],
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 21 – KEY TAKE-HOME POINTS
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("Key Take-Home Points", C.navyMid);

  const points = [
    { icon: "💊", msg: "AMIDES are ED workhorses (Lidocaine, Bupivacaine) — metabolised hepatically. Two 'i's = amide." },
    { icon: "📐", msg: "CALCULATE before you inject — always work in mg based on patient weight. 1% = 10 mg/mL." },
    { icon: "💉", msg: "EPINEPHRINE is your friend — except in end-organ vessels (digits, penis, nose, ears) & infected tissue." },
    { icon: "🧪", msg: "INFECTED TISSUE resists LA because acidic pH increases ionisation. Inject around, not into." },
    { icon: "🚨", msg: "LAST is life-threatening — tinnitus → metallic taste → seizures → cardiac arrest. Keep Intralipid 20% in the ED." },
    { icon: "🦴", msg: "NERVE BLOCKS are underused in EM — FICB, hematoma blocks & digital blocks spare opioids." },
    { icon: "🔵", msg: "METHEMOGLOBINEMIA — blue patient + SpO₂ 85% after benzocaine = MetHb. Treat with methylene blue." },
  ];

  points.forEach((p, i) => {
    const y = 0.88 + i * 0.66;
    sl.addShape(pres.shapes.RECTANGLE, {
      x: 0.2, y, w: 9.6, h: 0.58,
      fill: { color: i % 2 === 0 ? "E8F4FB" : "F7FBFF" },
      line: { color: i % 2 === 0 ? "AED6F1" : "D5E8F5" }
    });
    sl.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 0.08, h: 0.58, fill: { color: C.teal }, line: { color: C.teal } });
    sl.addText(p.icon, { x: 0.35, y, w: 0.5, h: 0.58, fontSize: 18, align: "center", valign: "middle" });
    sl.addText(p.msg, { x: 0.9, y: y + 0.04, w: 8.8, h: 0.5, fontSize: 12.5, color: C.navyMid, fontFace: "Calibri", valign: "middle" });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 22 – VIVA QUESTIONS
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = contentSlide("Viva / Exam Questions on This Topic", C.navyMid);

  const questions = [
    "What is the maximum dose of lidocaine plain and with epinephrine? How do you calculate it?",
    "Why does local anesthetic fail in infected tissue?",
    "What is the antidote for LAST? Give the dose and mechanism.",
    "Why is bupivacaine more cardiotoxic than lidocaine?",
    "Blue patient, SpO₂ 85%, not improving with O₂, after benzocaine spray — diagnosis and treatment?",
    "What is the difference between a field block and a nerve block?",
    "What is the mechanism of epinephrine when added to LA?",
    "Name 5 nerve blocks that can be performed by an emergency physician at the bedside.",
  ];

  questions.forEach((q, i) => {
    const y = 0.88 + i * 0.6;
    sl.addShape(pres.shapes.RECTANGLE, {
      x: 0.2, y, w: 9.6, h: 0.52,
      fill: { color: i % 2 === 0 ? "EBF5FB" : "F7FBFF" },
      line: { color: i % 2 === 0 ? "AED6F1" : "D5E8F5" }
    });
    sl.addText([
      { text: "Q" + (i + 1) + ". ", options: { bold: true, color: C.red, fontSize: 13 } },
      { text: q, options: { color: C.navyMid, fontSize: 12 } }
    ], { x: 0.32, y: y + 0.04, w: 9.3, h: 0.44, fontFace: "Calibri", valign: "middle" });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 23 – REFERENCES
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.navy };
  sl.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C.teal }, line: { color: C.teal } });

  sl.addText("REFERENCES", {
    x: 0.4, y: 0.2, w: 9.4, h: 0.55,
    fontSize: 28, bold: true, color: C.white, charSpacing: 3, fontFace: "Calibri"
  });
  sl.addShape(pres.shapes.RECTANGLE, { x: 0.4, y: 0.8, w: 8.0, h: 0.025, fill: { color: C.teal }, line: { color: C.teal } });

  const refs = [
    "Tintinalli JE et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9th Ed. McGraw-Hill. Chapter 36: Local and Regional Anesthesia.",
    "Pfenninger JL, Fowler GC. Procedures for Primary Care, 3rd Ed. Elsevier. Chapter 4: Local Anesthesia.",
    "Katzung BG. Basic and Clinical Pharmacology, 16th Ed. Chapter: Local Anesthetics.",
    "Gawel RJ et al. Emergency physician-performed ultrasound-guided nerve blocks: A scoping review. Am J Emerg Med. 2025 Nov. PMID: 40773853",
    "Gamberini L et al. Regional anesthesia in blunt thoracic trauma: Bayesian network meta-analysis. Am J Emerg Med. 2025 Mar. PMID: 39740311",
    "Bailey JG et al. Local anesthetic dosing for fascial plane blocks to avoid systemic toxicity. Can J Anaesth. 2025 Sep. PMID: 40954415",
    "ASRA/ESRA Checklist for LAST Management 2023 — asra.com",
  ];

  refs.forEach((ref, i) => {
    sl.addText([
      { text: String(i + 1) + ".  ", options: { bold: true, color: C.teal } },
      { text: ref, options: { color: C.textLight } }
    ], { x: 0.4, y: 0.95 + i * 0.6, w: 9.35, h: 0.55, fontSize: 11.5, fontFace: "Calibri" });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 24 – THANK YOU
// ══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.navy };

  sl.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.08, fill: { color: C.red }, line: { color: C.red } });
  sl.addShape(pres.shapes.RECTANGLE, { x: 0, y: 5.545, w: 10, h: 0.08, fill: { color: C.red }, line: { color: C.red } });

  sl.addShape(pres.shapes.RECTANGLE, {
    x: 1.0, y: 0.9, w: 8.0, h: 3.8,
    fill: { color: C.navyLight },
    shadow: { type: "outer", color: "000000", blur: 20, offset: 4, angle: 135, opacity: 0.4 }
  });
  sl.addShape(pres.shapes.RECTANGLE, { x: 1.0, y: 0.9, w: 0.22, h: 3.8, fill: { color: C.teal }, line: { color: C.teal } });

  sl.addText("THANK YOU", {
    x: 1.4, y: 1.2, w: 7.3, h: 1.0,
    fontSize: 52, bold: true, color: C.white, charSpacing: 6, align: "center", fontFace: "Calibri"
  });
  sl.addShape(pres.shapes.RECTANGLE, { x: 2.5, y: 2.28, w: 5.0, h: 0.025, fill: { color: C.teal }, line: { color: C.teal } });
  sl.addText("Questions & Discussion Welcome", {
    x: 1.4, y: 2.42, w: 7.3, h: 0.5,
    fontSize: 18, color: C.textLight, align: "center", fontFace: "Calibri"
  });
  sl.addText("Local Anesthesia in Emergency Medicine", {
    x: 1.4, y: 3.1, w: 7.3, h: 0.4,
    fontSize: 14, color: C.teal, align: "center", fontFace: "Calibri"
  });
  sl.addText("PG Year 1 | Emergency Medicine | Pudukkottai Medical College | July 2026", {
    x: 1.4, y: 3.62, w: 7.3, h: 0.35,
    fontSize: 11, color: C.midGray, align: "center", fontFace: "Calibri"
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// WRITE FILE
// ══════════════════════════════════════════════════════════════════════════════
pres.writeFile({ fileName: "/home/daytona/workspace/local-anesthesia-em/Local_Anesthesia_in_EM.pptx" })
  .then(() => console.log("SUCCESS: File saved!"))
  .catch(err => console.error("ERROR:", err));
Running Command

cd /home/daytona/workspace/local-anesthesia-em && node build.js

Running Command

node -e "const p = require('pptxgenjs'); const pres = new p(); console.log(Objec…

Running Command

node -e " const p = require('pptxgenjs'); const pres = new p(); const sl = pres.…

Running Command

node -e " const p = require('pptxgenjs'); const pres = new p(); const sl = pres.…

Running Command

node -e "const p = require('pptxgenjs'); const pres = new p(); console.log(Objec…

Running Command

grep -n "ELLIPSE" /home/daytona/workspace/local-anesthesia-em/build.js | head -2…

Running Command

sed -i 's/pres\.shapes\.ELLIPSE/pres.shapes.OVAL/g' /home/daytona/workspace/loca…

Running Command

python3 -c " content = open('/home/daytona/workspace/local-anesthesia-em/build.j…

Running Command

cd /home/daytona/workspace/local-anesthesia-em && node build.js 2>&1

Your presentation is ready. Here's your download link:

Local Anesthesia in EM

Presentation · PPTX

What's inside (24 slides):
SectionSlides
Title & IntroductionSlides 1-3
Section 1: PharmacologySlides 4-8
Esters vs Amides classificationSlide 4
Mechanism of action + nerve fiber orderSlide 5
pKa / protein binding / lipid solubilitySlide 6
Full dosing reference tableSlide 7
Role of epinephrine + contraindicationsSlide 8
Section 2: LASTSlides 9-11
Risk factors & overviewSlide 9
Clinical progression diagramSlide 10
Full management protocol with Intralipid dosingSlide 11
Section 3: TechniquesSlides 12-17
Routes overviewSlide 12
Topical agents tableSlide 13
Infiltration technique + pain reduction tipsSlide 14
All ED nerve blocks tableSlide 15
Fascia Iliaca Block deep diveSlide 16
Hematoma block techniqueSlide 17
Section 4: Special TopicsSlides 18-19
Special populationsSlide 18
MethemoglobinemiaSlide 19
Quick reference / Summary / Viva Qs / ReferencesSlides 20-24
Design: Navy blue + red/teal accent scheme - professional and medically appropriate. Section dividers, numbered steps, color-coded tables, and clinical pearls throughout.
This is a shared conversation. Sign in to Orris to start your own chat.