create management protocol for all the types of shock

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I now have comprehensive information from multiple authoritative textbooks. Let me compile this into a complete management protocol document.

Management Protocol for All Types of Shock

Based on: Mulholland & Greenfield's Surgery (7e), Barash Clinical Anesthesia (9e), Rosen's Emergency Medicine, Sabiston Textbook of Surgery, Tintinalli's Emergency Medicine

Overview: Classification of Shock

Shock is defined as inadequate tissue oxygen delivery relative to demand, resulting in cellular hypoxia and organ dysfunction. The Weil-Shubin classification (1971) divides shock into four categories:

Type	Cardiac Output	SVR	PAOP	CVP	SvO2
Hypovolemic	↓	↑	↓	↓	↓
Cardiogenic (LV)	↓	↑	↑	N/↑	↓
Cardiogenic (RV)	↓	↑	N/↓	↑	↓
Obstructive (tamponade/PE)	↓	↑	↑	↑	↓
Distributive (early)	↑/N/↓	↓	N	N/↑	N/↑
Distributive (late)	↓	↑	N	N	↓

SVR = systemic vascular resistance; PAOP = pulmonary artery occlusion pressure; CVP = central venous pressure; SvO2 = mixed venous O2 saturation

Universal Initial Assessment (All Shock Types)

Immediate actions (first 5-10 minutes):

Airway - secure and protect; intubate if GCS <8 or unable to protect airway
Breathing - supplemental O2; target SpO2 >94%; consider early mechanical ventilation
Circulation - 2 large-bore IV lines; attach cardiac monitor; 12-lead ECG
Rapid assessment - HR, BP (both arms), RR, SpO2, temp, capillary refill, mental status
Point-of-care ultrasound (POCUS) - essential to differentiate shock type (cardiac function, IVC collapsibility, lung sliding, pericardial fluid)

Labs (all types):

CBC, BMP, LFTs, coagulation panel (PT/INR/aPTT)
Lactate (arterial or venous) - target clearance ≥10% per 2 hours
ABG, blood type and crossmatch
Blood cultures x2 (before antibiotics if infection suspected)
Troponin, BNP/NT-proBNP

Monitoring targets (endpoints of resuscitation):

MAP ≥65 mmHg (≥80 in neurogenic shock)
Urine output ≥0.5 mL/kg/hr
Lactate normalization (<2 mmol/L)
ScvO2 >70% (via central venous catheter)
SOFA score improvement

1. HYPOVOLEMIC SHOCK

Pathophysiology

Reduction in circulating intravascular volume preventing adequate cardiac output. Most common type in surgical practice. Requires >20% loss of circulating volume.

Causes

Hemorrhagic: trauma, GI bleed, ruptured AAA, ectopic pregnancy, postpartum hemorrhage
Non-hemorrhagic: burns, pancreatitis, GI losses (vomiting/diarrhea), renal losses (DI, adrenal crisis), third-spacing

ATLS Classification (Hemorrhagic Shock)

Class	Blood Loss	HR	SBP	RR	UO (mL/hr)	Mental Status
I	<15% (<750 mL)	<100	Normal	14-20	>30	Normal
II	15-30% (750-1500 mL)	100-120	Normal	20-30	20-30	Anxious
III	30-40% (1500-2000 mL)	120-140	↓	30-40	5-15	Confused
IV	>40% (>2000 mL)	>140	Very ↓	>35	<5	Lethargic/comatose

Management Protocol

Step 1 - Stop the source

Surgical control of bleeding (hemorrhage control takes priority over resuscitation in penetrating trauma)
Tourniquet for extremity hemorrhage
Pressurize wound with direct pressure or hemostatic gauze

Step 2 - Fluid resuscitation

Class I-II: Crystalloid (Lactated Ringer's preferred over normal saline - balanced solutions reduce hyperchloremic acidosis). 1-2 L bolus IV; reassess.
Class III: Crystalloid + packed red blood cells (pRBCs). Balanced crystalloids (LR) preferred.
Class IV (hemorrhagic): Damage Control Resuscitation (DCR):
- 1:1:1 ratio of pRBCs : FFP : platelets
- Permissive hypotension (target SBP 80-90 mmHg) until surgical hemorrhage control in penetrating trauma - avoid in TBI
- Tranexamic acid (TXA) 1 g IV over 10 min, then 1 g over 8 hrs - give within 3 hours of injury
- Avoid excessive crystalloid (associated with coagulopathy, hypothermia, acidosis - "lethal triad")
Non-hemorrhagic: Crystalloid resuscitation; address underlying electrolyte abnormality (gastric vs. colonic losses differ)

Step 3 - Vasopressors (if fluid-refractory)

Norepinephrine 0.01-3 mcg/kg/min (first-line if MAP persistently <65 despite fluid)
Vasopressors in hemorrhagic shock increase mortality - use sparingly and only after adequate volume replacement

Step 4 - Monitor

Urine output (Foley catheter)
Serial lactate q2h
Hgb/Hct, ionized calcium (hypocalcemia with massive transfusion)
Temperature - keep warm; hypothermia worsens coagulopathy
Calcium chloride 1 g IV per 4 units pRBC (for massive transfusion)

2. CARDIOGENIC SHOCK

Pathophysiology

Decreased cardiac output despite adequate preload, with resulting tissue hypoperfusion. The heart fails as a pump.

Causes

Myocardial: Anterior wall MI (most common), non-ischemic cardiomyopathy, myocarditis, toxin/drug-induced (beta-blockers, CCBs, TCAs, anthracyclines), metabolic (hypocalcemia, hypophosphatemia, acidosis)
Valvular: ruptured papillary muscle, acute MR, acute AS/AR
Arrhythmic: VT/VF, complete heart block, severe bradycardia

Diagnosis

Clinical: pulmonary rales, S3 gallop, JVD, pink frothy sputum, bilateral infiltrates on CXR
Echo: reduced EF, wall motion abnormalities, valvular pathology
Labs: elevated troponin, BNP; low ScvO2; rising lactate
Hemodynamics: CI <2.2 L/min/m², PAOP >18 mmHg, MAP <65 mmHg

Management Protocol

Step 1 - Identify and treat the cause immediately

Ischemic/STEMI: Emergent PCI (primary reperfusion is the most important intervention). Fibrinolysis if PCI unavailable within 120 min.
Arrhythmia: Cardioversion/defibrillation for VT/VF; pacing for complete heart block
Mechanical complication (papillary rupture, VSD): Urgent surgical repair
Non-ischemic decompensated HF: Beta-blockers and diuresis have an increasing role

Step 2 - Hemodynamic support

Fluid: Cautious fluid challenge (250 mL bolus); avoid aggressive loading (worsens pulmonary edema). Give only if PAOP/CVP low or patient appears volume-depleted.
Vasopressors/Inotropes:
- Norepinephrine 0.01-0.5 mcg/kg/min - first-line vasopressor (maintains MAP, less arrhythmogenic than dopamine)
- Dobutamine 2-20 mcg/kg/min - add for inotropic support when CI is low and MAP acceptable
- Epinephrine - avoid if possible; associated with poor short-term survival in cardiogenic shock
- Vasopressin - second-line vasopressor; reduces catecholamine requirements
Vasodilators (only in non-hypotensive patients): Nitroglycerin or sodium nitroprusside IV - reduce preload/afterload; contraindicated if SBP <90 mmHg

Step 3 - Mechanical circulatory support (MCS)

Intra-aortic balloon pump (IABP): Reduces afterload, augments diastolic coronary perfusion. Used as bridge to PCI/surgery. Note: IABP-SHOCK II trial showed no mortality benefit over medical therapy alone.
Impella (axial flow pump): Greater hemodynamic support than IABP; increasingly used as bridge to recovery or transplant
VA-ECMO: For refractory cardiogenic shock; provides full cardiopulmonary bypass

Step 4 - Supportive care

Diuresis (furosemide) once hemodynamically stable to reduce pulmonary congestion
Intubation and mechanical ventilation if severe respiratory distress (reduces work of breathing and myocardial O2 demand)
Avoid beta-blockers acutely in ischemic cardiogenic shock
Avoid aggressive diuresis in RV infarction (RV is preload-dependent)
For RV infarction: IV fluids cautiously, norepinephrine, avoid nitrates (reduce RV preload), maintain AV synchrony

3. DISTRIBUTIVE SHOCK

Distributive shock results from inappropriate vasodilation and redistribution of blood flow, reducing effective perfusion despite normal or elevated cardiac output. Subtypes: septic, anaphylactic, neurogenic, endocrine.

3a. SEPTIC SHOCK

Definition (Sepsis-3)

Sepsis = suspected infection + SOFA score increase ≥2. Septic shock = sepsis + vasopressor requirement + lactate >2 mmol/L.

Management Protocol

Hour 1 Bundle (CMS SEP-1):

Measure lactate; remeasure if initial >2 mmol/L
Blood cultures x2 before antibiotics
Broad-spectrum antibiotics within 1 hour
30 mL/kg IV crystalloid for hypotension or lactate ≥4 mmol/L
Vasopressors if MAP <65 mmHg despite fluid resuscitation

Antibiotics (within 1 hour - do NOT delay for cultures):

Empirical broad-spectrum coverage: piperacillin-tazobactam OR meropenem/imipenem (if high resistance risk)
Add vancomycin if MRSA suspected (IV catheter infection, known colonization)
Add antifungals if Candida risk factors (prolonged ICU, immunocompromised, TPN)
De-escalate based on culture results (48-72 hrs)
Duration: typically 7-10 days; shorter courses acceptable if clinically improved

Source control:

Drain abscesses, remove infected catheters, debride infected tissue
Surgical intervention within 6-12 hours if indicated (perforated viscus, necrotizing fasciitis)

Fluid resuscitation:

30 mL/kg balanced crystalloid (LR preferred over NS - reduces hyperchloremia and AKI)
Reassess after each bolus with clinical exam, POCUS, pulse pressure variation
Albumin 20-25% may be considered in patients who have received large crystalloid volumes
Avoid starches (HES) - associated with increased AKI and mortality

Vasopressors:

Norepinephrine: first-line, 0.01-3 mcg/kg/min via central venous catheter (or IO if no central access)
Vasopressin 0.03-0.04 units/min: add to reduce norepinephrine dose (reduces catecholamine toxicity); second-line
Epinephrine: third-line or when bradycardia coexists
Dopamine: no longer recommended as first-line; associated with more arrhythmias
Angiotensin II (Giapreza): for refractory vasodilatory shock

Corticosteroids:

Hydrocortisone 200 mg/day IV (continuous infusion or 50 mg q6h) if shock refractory to norepinephrine >0.25 mcg/kg/min for >4 hours
Do NOT use dexamethasone (lacks mineralocorticoid effect)
Taper when vasopressors weaned

Glucose control:

Target blood glucose 140-180 mg/dL
Avoid tight glucose control (<110 mg/dL) - associated with hypoglycemia and harm

Organ support:

Lung-protective ventilation if ARDS: TV 6 mL/kg ideal body weight, plateau pressure <30 cmH2O
Prone positioning for P/F ratio <150
Renal replacement therapy if refractory AKI with volume overload, acidosis, or hyperkalemia

Monitoring endpoints:

Lactate clearance ≥10% per 2 hours (target <2 mmol/L)
ScvO2 >70%
MAP ≥65 mmHg
Urine output ≥0.5 mL/kg/hr

3b. ANAPHYLACTIC SHOCK

Triggers

Food (nuts, shellfish), insect stings, medications (penicillin, NSAIDs, contrast dye, muscle relaxants), latex.

Diagnosis

Anaphylaxis is likely if ANY of the following after allergen exposure:

Skin/mucosal symptoms (urticaria, angioedema, flushing) PLUS respiratory compromise OR hypotension
Two or more organ systems involved after allergen exposure
Hypotension alone after known allergen exposure

Management Protocol

Step 1 - Epinephrine (FIRST LINE - no absolute contraindications)

IM epinephrine 0.3-0.5 mg (1:1000) in the anterolateral thigh - repeat every 5-15 min as needed (2-3 doses)
If refractory or cardiovascular collapse: IV epinephrine 0.1-0.2 mg (1:10,000) slow IV push; then continuous infusion 0.1-1 mcg/kg/min
Glucagon 1-2 mg IV/IM (for patients on beta-blockers who fail to respond to epinephrine - overcomes beta-blockade)

Step 2 - Position and airway

Supine with legs elevated (improves venous return)
Supplemental O2 via non-rebreather mask; prepare for early intubation (angioedema can progress rapidly)
Cricothyrotomy tray at bedside if laryngeal edema severe

Step 3 - IV fluids

1-2 L crystalloid IV rapidly for hypotension
Large volumes may be needed due to massive capillary leak

Step 4 - Second-line agents (DO NOT replace or precede epinephrine)

H1 antihistamine: Diphenhydramine 25-50 mg IV (for urticaria/pruritus - does NOT prevent shock)
H2 antihistamine: Ranitidine or famotidine IV (complementary)
Corticosteroids: Methylprednisolone 125 mg IV or hydrocortisone 200 mg IV (prevent biphasic reaction, onset delayed 4-6 hrs)
Bronchodilator: Salbutamol/albuterol nebulization for bronchospasm

Step 5 - Observation and discharge

Observe minimum 4-6 hours (biphasic reactions in 5-20% of patients, occurring up to 72 hrs)
Admit for: refractory hypotension, airway involvement, unknown trigger, IV epinephrine used
Discharge: prescribe 2 self-injectable epinephrine devices (EpiPen), oral antihistamine, oral steroid course, allergist referral
Medic alert bracelet

3c. NEUROGENIC SHOCK

Pathophysiology

Loss of sympathetic tone from spinal cord injury (typically T6 and above), causing vasodilation and relative bradycardia (unlike other shock states where tachycardia predominates). Distinguishes from spinal shock (loss of reflexes - a neurological, not hemodynamic, phenomenon).

Diagnosis

Classic triad: Hypotension + bradycardia + hypothermia
Must be differentiated from hemorrhagic shock (also common in trauma patients with SCI)
POCUS: normal/hyperdynamic cardiac function, non-collapsing IVC

Management Protocol

Step 1 - Spinal immobilization and neuroprotection

Immobilize cervical spine
Methylprednisolone: no longer routinely recommended (controversial; consider only within 8 hrs of injury per NASCIS-2 if institutional protocol)
Maintain MAP 85-90 mmHg (higher target than other shock states to optimize spinal cord perfusion)

Step 2 - Fluid resuscitation

Isotonic crystalloid to restore circulating volume
Avoid over-resuscitation (patients may develop pulmonary edema without sympathetic tone)

Step 3 - Vasopressors (first-line in neurogenic shock)

Norepinephrine or phenylephrine (alpha-1 agonists) - preferred; restore vascular tone
Dopamine - useful if bradycardia is significant (has both alpha and beta-1 effects)
Atropine 0.5-1 mg IV for symptomatic bradycardia; may need temporary transvenous pacing for refractory cases

Step 4 - Temperature management

External warming (patients are poikilothermic below level of injury)

Step 5 - Monitoring

MAP target 85-90 mmHg x 5-7 days to optimize cord perfusion
Foley catheter (bladder dysfunction)
Bowel care (paralytic ileus common)
DVT prophylaxis (early, given high clot risk)

3d. ENDOCRINE/ADRENAL CRISIS SHOCK

Causes

Primary adrenal insufficiency (Addison's, bilateral adrenal hemorrhage/infarction), abrupt steroid withdrawal, pituitary apoplexy.

Diagnosis

Refractory vasodilatory shock unresponsive to fluids/vasopressors + hyponatremia + hyperkalemia + hypoglycemia + eosinophilia; low morning cortisol (<3 mcg/dL); poor response to ACTH stimulation test.

Management Protocol

Do not wait for lab confirmation - treat empirically if clinical suspicion high
Hydrocortisone 100 mg IV bolus, then 50 mg IV q6h or 200 mg/day continuous infusion
Dextrose-containing fluid (D5NS or D5LR) - correct hypoglycemia
1-2 L isotonic saline rapidly (correct hypovolemia and hyponatremia cautiously)
Vasopressors as needed (typically respond to steroids within 1-2 hrs)
Identify and treat precipitating cause (infection, surgery, trauma)

4. OBSTRUCTIVE SHOCK

Pathophysiology

Mechanical obstruction to blood flow preventing adequate cardiac output. Includes: tension pneumothorax, cardiac tamponade, massive pulmonary embolism, and severe pulmonary hypertension.

Hemodynamic Pattern

Low CO, high CVP/PAOP, high SVR - similar to cardiogenic shock, but the problem is mechanical, not pump failure.

4a. TENSION PNEUMOTHORAX

Diagnosis (clinical - DO NOT wait for CXR)

Absent breath sounds unilaterally + tracheal deviation (late sign)
Severe respiratory distress + hypotension + JVD
POCUS: absent lung sliding on affected side; M-mode "barcode sign"

Management

Immediate needle decompression - 2nd intercostal space, midclavicular line (or 4th-5th ICS, anterior axillary line if obese) - 14G angiocath, minimum 8 cm length
Definitive treatment: chest tube thoracostomy - 4th or 5th ICS, anterior axillary line; 28-32Fr tube (trauma); or finger thoracostomy in cardiac arrest
Bilateral decompressions in traumatic arrest before thoracotomy
No time for imaging - treat clinically

4b. CARDIAC TAMPONADE

Diagnosis

Beck's triad: Hypotension + JVD + muffled heart sounds (classic but only present in 10-40%)
Pulsus paradoxus >10 mmHg (exaggerated fall in SBP with inspiration)
ECG: electrical alternans, low voltage, sinus tachycardia
POCUS (diagnostic gold standard): Pericardial effusion + RV collapse in diastole + IVC dilation without respiratory variation; swinging heart

Management

Aggressive IV fluids to maintain preload while preparing for drainage
Pericardiocentesis (emergency or guided by echo):
- Subxiphoid approach; aspirate 10-20 mL can restore hemodynamics dramatically
- Echo-guided preferred if time allows (reduces complications)
Surgical pericardiotomy/window if: traumatic tamponade (clotted blood), recurrent tamponade, hemopericardium
Emergency thoracotomy in traumatic cardiac arrest with tamponade
Avoid positive pressure ventilation if possible (reduces venous return)
Avoid vasodilators and diuretics (both worsen preload)
Maintain heart rate (tachycardia is compensatory - do not give beta-blockers)

4c. MASSIVE PULMONARY EMBOLISM

Diagnosis

PE with hemodynamic instability: SBP <90 mmHg or vasopressor requirement + evidence of RV dysfunction.

POCUS: RV enlargement (RV:LV ratio >0.9), septal bowing (D-sign), McConnell's sign, dilated IVC
CT-PA (if stable enough): filling defect in main/bilateral PAs + RV strain
ECG: S1Q3T3, new RBBB, sinus tachycardia

Management

Anticoagulation immediately (unless absolute contraindication): UFH 80 units/kg IV bolus, then 18 units/kg/hr infusion
Systemic thrombolysis (first-line reperfusion for massive PE):
- Alteplase (tPA) 100 mg IV over 2 hrs (or 0.6 mg/kg over 15 min in cardiac arrest)
- Contraindications: active bleeding, recent stroke, prior intracranial surgery, pregnancy
Surgical embolectomy: If thrombolysis is contraindicated or fails; requires cardiopulmonary bypass
Catheter-directed thrombolysis/thrombectomy (CDTT): For sub-massive PE or when systemic lysis is contraindicated; reduced dose tPA delivered directly into clot
Supportive care:
- Cautious IV fluids (RV is dilated and failing; excessive fluids cause septal shift and LV compromise)
- Vasopressors: norepinephrine first-line; vasopressin as adjunct
- Avoid dobutamine alone (may cause systemic vasodilation)
- Intubation: use carefully (positive pressure ventilation decreases venous return and can precipitate arrest)
- VA-ECMO: bridge to surgical embolectomy in refractory cases

Vasopressor/Inotrope Quick Reference

Drug	Mechanism	Dose	Primary Use
Norepinephrine	α1 > β1	0.01-3 mcg/kg/min	First-line all shock types except anaphylaxis
Epinephrine	α1, β1, β2	0.01-1 mcg/kg/min	Anaphylaxis (IM first), refractory septic shock
Vasopressin	V1 receptors	0.03-0.04 units/min	Second-line adjunct to NE in septic/distributive
Dobutamine	β1 > β2	2-20 mcg/kg/min	Cardiogenic shock (add-on for inotropic support)
Phenylephrine	α1 only	0.5-9 mcg/kg/min	Neurogenic shock; tachycardia with vasodilation
Dopamine	D1, β1, α1 (dose-dependent)	5-20 mcg/kg/min	No longer first-line; use if bradycardia present
Angiotensin II	AT1 receptors	20-40 ng/kg/min	Refractory vasodilatory shock

Monitoring and Endpoints of Resuscitation

Parameter	Target
MAP	≥65 mmHg (≥85-90 in neurogenic)
Urine output	≥0.5 mL/kg/hr
Lactate	<2 mmol/L; ≥10% clearance per 2 hrs
ScvO2	>70%
Blood glucose	140-180 mg/dL
Temperature	≥36°C (normothermia)
pH	7.35-7.45
Ionized Ca2+	>1.1 mmol/L (especially with massive transfusion)

SOFA Score (Sepsis Severity Assessment)

System	Score 0	1	2	3	4
Respiratory PaO2/FiO2	>400	301-400	201-300	101-200	≤100
Cardiovascular	MAP >70	MAP <70 (no vasopressor)	Dopa ≤5 or any dobutamine	Dopa >5 or NE ≤0.1	NE >0.1 or any vasopressin
Coagulation (plt ×10⁹/L)	>150	100-149	50-99	20-49	<20
Renal Cr (mg/dL)	<1.2	1.2-1.9	2.0-3.4	3.5-4.9	>5
Liver bili (mg/dL)	<1.2	1.2-1.9	2.0-5.9	6.0-11.9	>12
Neuro (GCS)	15	13-14	10-12	6-9	<6

Differential Diagnosis by POCUS

Finding	Most Likely Type
Hyperdynamic heart, small IVC	Distributive (septic/anaphylactic/neurogenic)
Dilated, poor LV function, B-lines on lung	Cardiogenic
Small heart, small IVC, no effusion	Hypovolemic
Pericardial effusion + RV diastolic collapse	Tamponade (obstructive)
RV enlargement, D-sign, no effusion	PE (obstructive)
Absent lung sliding unilaterally	Tension pneumothorax (obstructive)

Create a decision tree flowchart to differentiate shock types using POCUS findings

Reading File

Running Command

ls -la /home/daytona/workspace/ && mkdir -p /home/daytona/workspace/shock-pocus-flowchart

Writing File

~/shock-pocus-flowchart/build.js

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pres.author = "Orris Medical";

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    fill: { color: color }, line: { color: color, width: 0 }, rectRadius: 0.12,
  });
  slide.addText(title, {
    x, y: y + 0.02, w, h: h * 0.52,
    fontSize: 12, bold: true, color: C.white, align: "center", valign: "bottom",
    fontFace: "Calibri",
  });
  if (sub) {
    slide.addText(sub, {
      x, y: y + h * 0.52, w, h: h * 0.46,
      fontSize: 9, color: C.white, align: "center", valign: "top",
      fontFace: "Calibri", italic: true,
    });
  }
}

// Arrow / connector line
function arrow(slide, x1, y1, x2, y2) {
  slide.addShape(pres.ShapeType.line, {
    x: x1, y: y1, w: x2 - x1, h: y2 - y1,
    line: { color: C.accent, width: 1.5, endArrowType: "open" },
  });
}

// Label along a connector
function label(slide, x, y, text, color) {
  slide.addText(text, {
    x, y, w: 0.7, h: 0.24,
    fontSize: 8, bold: true, color: color || C.yellow, align: "center",
  });
}

// ─── SLIDE 1: Title ───────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  titleSlide(s);
}

// ─── SLIDE 2: Overview – 3-Window POCUS Protocol ──────────────────────────────
{
  const s = pres.addSlide();
  applyBg(s);
  addHeader(s, "3-Window POCUS Protocol for Undifferentiated Shock", "Step-by-step ultrasound assessment");

  // Three window panels
  const panels = [
    {
      icon: "❤️", title: "CARDIAC WINDOW",
      sub: "Subxiphoid or Parasternal Long Axis",
      points: [
        "LV contractility (EF normal/reduced/hyperdynamic?)",
        "RV size (RV:LV ratio >0.9 = RV strain)",
        "Pericardial effusion present?",
        "Wall motion abnormalities?",
      ],
      color: C.red,
    },
    {
      icon: "💧", title: "IVC WINDOW",
      sub: "Subcostal, long axis, 2 cm from RA junction",
      points: [
        "IVC diameter: Small (<1.5 cm) / Normal / Dilated (>2.1 cm)",
        "Collapsibility Index (CI): >50% = volume responsive",
        "CI <50% + dilated IVC = elevated CVP",
        "Non-collapsible IVC = obstructive or cardiogenic",
      ],
      color: C.blue,
    },
    {
      icon: "🫁", title: "LUNG WINDOW",
      sub: "Anterior zones bilateral (2nd ICS MCL)",
      points: [
        "B-lines (≥3 per zone) = pulmonary edema/ARDS",
        "Absent lung sliding = pneumothorax (check both sides)",
        "Barcode sign on M-mode = absent sliding",
        "A-lines bilateral = normal or hypovolemia",
      ],
      color: C.green,
    },
  ];

  panels.forEach((p, i) => {
    const x = 0.35 + i * 4.32;
    // Panel background
    slide_panel(s, x, 1.0, 4.1, 5.9, p, i);
  });

  // Footer note
  s.addText("Always perform all 3 windows. Findings are integrated — no single window is diagnostic in isolation.", {
    x: 0.3, y: 7.1, w: 12.7, h: 0.3,
    fontSize: 10, color: C.grey, align: "center", italic: true,
  });

  function slide_panel(slide, x, y, w, h, p, idx) {
    slide.addShape(pres.ShapeType.roundRect, {
      x, y, w, h,
      fill: { color: C.bgLight }, line: { color: p.color, width: 2 }, rectRadius: 0.15,
    });
    // Header band
    slide.addShape(pres.ShapeType.roundRect, {
      x, y, w, h: 1.0,
      fill: { color: p.color }, line: { color: p.color }, rectRadius: 0.15,
    });
    // Square off bottom of header band
    slide.addShape(pres.ShapeType.rect, {
      x, y: y + 0.7, w, h: 0.3,
      fill: { color: p.color }, line: { color: p.color },
    });
    slide.addText(p.icon, { x, y: y + 0.06, w, h: 0.5, fontSize: 26, align: "center" });
    slide.addText(p.title, {
      x, y: y + 0.5, w, h: 0.45,
      fontSize: 12, bold: true, color: C.white, align: "center", valign: "middle",
    });
    slide.addText(p.sub, {
      x: x + 0.1, y: y + 1.05, w: w - 0.2, h: 0.38,
      fontSize: 9, color: p.color, align: "center", italic: true,
    });
    // Bullet points
    const items = p.points.map((pt, j) => ({
      text: pt,
      options: { bullet: { type: "bullet" }, breakLine: j < p.points.length - 1, fontSize: 10, color: C.dimWhite },
    }));
    slide.addText(items, {
      x: x + 0.15, y: y + 1.48, w: w - 0.3, h: h - 1.6,
      fontFace: "Calibri", valign: "top",
    });
  }
}

// ─── SLIDE 3: Master Decision Tree ────────────────────────────────────────────
{
  const s = pres.addSlide();
  applyBg(s);
  addHeader(s, "Master Decision Tree  —  POCUS Shock Differentiation", "All 4 shock categories");

  // Start node
  s.addShape(pres.ShapeType.ellipse, { x: 5.4, y: 0.9, w: 2.5, h: 0.65, fill: { color: C.accent }, line: { color: C.accent } });
  s.addText("UNDIFFERENTIATED SHOCK", { x: 5.4, y: 0.9, w: 2.5, h: 0.65, fontSize: 9, bold: true, color: C.boxText, align: "center", valign: "middle" });

  // Arrow down from start
  arrow(s, 6.65, 1.55, 6.65, 2.0);

  // Q1 – Cardiac view
  qBox(s, 5.1, 2.0, 3.1, 0.65, "Q1: Is there a PERICARDIAL EFFUSION\n+ RV diastolic collapse?", C.accent);

  // YES → Tamponade
  arrow(s, 5.1, 2.32, 3.9, 2.32);
  label(s, 4.3, 2.1, "YES", C.yellow);
  diagBox(s, 2.45, 1.95, 1.45, 0.78, "CARDIAC\nTAMPONADE", "Obstructive", C.purple);

  // NO arrow down
  arrow(s, 6.65, 2.65, 6.65, 3.1);
  label(s, 6.72, 2.74, "NO", C.orange);

  // Q2 – Lung sliding
  qBox(s, 5.1, 3.1, 3.1, 0.65, "Q2: Is there ABSENT LUNG SLIDING\n(+ barcode sign on M-mode)?", C.accent);

  // YES → Tension PTX
  arrow(s, 5.1, 3.42, 3.9, 3.42);
  label(s, 4.3, 3.22, "YES", C.yellow);
  diagBox(s, 2.45, 3.05, 1.45, 0.78, "TENSION\nPNEUMOTHORAX", "Obstructive", C.purple);

  // NO arrow down
  arrow(s, 6.65, 3.75, 6.65, 4.2);
  label(s, 6.72, 3.84, "NO", C.orange);

  // Q3 – RV strain
  qBox(s, 5.1, 4.2, 3.1, 0.65, "Q3: RV:LV ratio >0.9 + D-sign\n+ non-collapsible IVC?", C.accent);

  // YES → PE
  arrow(s, 5.1, 4.52, 3.9, 4.52);
  label(s, 4.3, 4.32, "YES", C.yellow);
  diagBox(s, 2.45, 4.15, 1.45, 0.78, "MASSIVE\nPULM. EMBOLISM", "Obstructive", C.purple);

  // NO arrow down
  arrow(s, 6.65, 4.85, 6.65, 5.3);
  label(s, 6.72, 4.94, "NO", C.orange);

  // Q4 – LV function
  qBox(s, 5.1, 5.3, 3.1, 0.65, "Q4: Is LV function SEVERELY REDUCED\n(EF <30%) + dilated/congested?", C.accent);

  // YES → Cardiogenic
  arrow(s, 5.1, 5.62, 3.9, 5.62);
  label(s, 4.3, 5.42, "YES", C.yellow);
  diagBox(s, 2.45, 5.25, 1.45, 0.78, "CARDIOGENIC\nSHOCK", "Low CO, high PAOP", C.red);

  // NO arrow down
  arrow(s, 6.65, 5.95, 6.65, 6.38);
  label(s, 6.72, 6.04, "NO", C.orange);

  // Q5 – IVC collapsibility
  qBox(s, 5.1, 6.38, 3.1, 0.65, "Q5: Is the IVC SMALL + COLLAPSIBLE\n(CI >50%, IVC <1.5 cm)?", C.accent);

  // YES → Hypovolemic
  arrow(s, 5.1, 6.7, 3.9, 6.7);
  label(s, 4.3, 6.5, "YES", C.yellow);
  diagBox(s, 2.45, 6.33, 1.45, 0.78, "HYPOVOLEMIC\nSHOCK", "Hemorrhage/Fluid loss", C.blue);

  // NO → Distributive
  arrow(s, 8.2, 6.7, 9.4, 6.7);
  label(s, 8.5, 6.5, "NO", C.orange);
  diagBox(s, 9.4, 6.33, 1.6, 0.78, "DISTRIBUTIVE\nSHOCK", "Septic/Anaph/Neurogen.", C.orange);

  // Legend panel
  s.addShape(pres.ShapeType.roundRect, {
    x: 10.55, y: 1.1, w: 2.5, h: 3.8,
    fill: { color: C.bgLight }, line: { color: C.greyDark }, rectRadius: 0.1,
  });
  s.addText("LEGEND", {
    x: 10.55, y: 1.12, w: 2.5, h: 0.35,
    fontSize: 11, bold: true, color: C.accent, align: "center",
  });

  const legendItems = [
    { color: C.accent,  label: "Decision question" },
    { color: C.purple,  label: "Obstructive shock" },
    { color: C.red,     label: "Cardiogenic shock" },
    { color: C.blue,    label: "Hypovolemic shock" },
    { color: C.orange,  label: "Distributive shock" },
    { color: C.yellow,  label: "YES branch" },
  ];
  legendItems.forEach((li, i) => {
    s.addShape(pres.ShapeType.roundRect, {
      x: 10.7, y: 1.55 + i * 0.55, w: 0.28, h: 0.28,
      fill: { color: li.color }, line: { color: li.color }, rectRadius: 0.04,
    });
    s.addText(li.label, {
      x: 11.05, y: 1.55 + i * 0.55, w: 1.9, h: 0.28,
      fontSize: 9.5, color: C.dimWhite, valign: "middle",
    });
  });
}

// ─── SLIDE 4: Branch A – Obstructive Shock Drill-Down ─────────────────────────
{
  const s = pres.addSlide();
  applyBg(s);
  addHeader(s, "Obstructive Shock  —  POCUS Drill-Down", "Tamponade · Tension PTX · Massive PE");

  // Obstructive header
  s.addShape(pres.ShapeType.roundRect, {
    x: 0.2, y: 0.95, w: 12.9, h: 0.55,
    fill: { color: C.purple }, line: { color: C.purple }, rectRadius: 0.1,
  });
  s.addText("🚨  OBSTRUCTIVE SHOCK PATHWAY  —  3 Life-Threatening Causes", {
    x: 0.2, y: 0.95, w: 12.9, h: 0.55,
    fontSize: 14, bold: true, color: C.white, align: "center", valign: "middle",
  });

  // ── TAMPONADE COLUMN ──────────────────────────────────────────────────────
  const col = (i) => 0.25 + i * 4.38;
  const colW = 4.1;

  // Column headers
  const colData = [
    { title: "CARDIAC TAMPONADE", icon: "❤️", color: C.red },
    { title: "TENSION PNEUMOTHORAX", icon: "🫁", color: C.green },
    { title: "MASSIVE PULM. EMBOLISM", icon: "🩸", color: C.pink },
  ];
  colData.forEach((c, i) => {
    s.addShape(pres.ShapeType.roundRect, {
      x: col(i), y: 1.6, w: colW, h: 0.5,
      fill: { color: c.color }, line: { color: c.color }, rectRadius: 0.1,
    });
    s.addText(`${c.icon}  ${c.title}`, {
      x: col(i), y: 1.6, w: colW, h: 0.5,
      fontSize: 11, bold: true, color: C.white, align: "center", valign: "middle",
    });
  });

  // Row 1: POCUS Findings
  const rows = [
    {
      label: "POCUS FINDINGS",
      items: [
        "• Pericardial effusion (any size)\n• RV diastolic collapse\n• RA systolic collapse\n• IVC dilated, non-collapsible\n• Swinging heart (large effusion)\n• Electrical alternans on ECG",
        "• Absent lung sliding on affected side\n• Barcode sign (M-mode)\n• No B-lines on affected side\n• Lung point (pathognomonic)\n• Contralateral tracheal shift (late)\n• Clinical: JVD + absent breath sounds",
        "• RV:LV ratio >0.9 (4-chamber view)\n• D-sign (septal bowing toward LV)\n• McConnell's sign (akinetic RV free wall,\n  preserved apical motion)\n• IVC dilated, non-collapsible\n• No pericardial effusion",
      ],
    },
    {
      label: "KEY DIFFERENTIATOR",
      items: [
        "Pericardial fluid + RV collapse\nin diastole is diagnostic",
        "Absent lung sliding ipsilateral.\nLung point = definitive.",
        "RV dilation + McConnell's sign.\nNo effusion.",
      ],
    },
    {
      label: "IMMEDIATE ACTION",
      items: [
        "Pericardiocentesis\n(subxiphoid route)\nFluid bolus as bridge",
        "Needle decompression\n2nd ICS MCL STAT\n→ Chest tube to follow",
        "UFH anticoagulation\nSystemic thrombolysis\n(tPA 100 mg over 2h)",
      ],
    },
    {
      label: "DO NOT",
      items: [
        "Do NOT give diuretics\nDo NOT give vasodilators\nDo NOT IPPV until drained",
        "Do NOT delay for CXR\nTreat on clinical suspicion",
        "Cautious IVF (RV dilated)\nDo NOT over-resuscitate",
      ],
    },
  ];

  const rowH = [1.45, 0.62, 0.78, 0.58];
  const rowColors = [C.bgLight, "1A3A5C", "1A3A5C", "2C1A1A"];
  let rowY = 2.18;
  rows.forEach((row, ri) => {
    // Row label
    s.addShape(pres.ShapeType.rect, {
      x: 0.25, y: rowY, w: 12.8, h: rowH[ri],
      fill: { color: rowColors[ri] }, line: { color: C.greyDark },
    });
    s.addText(row.label, {
      x: 0.28, y: rowY, w: 12.75, h: 0.26,
      fontSize: 9, bold: true, color: C.accent, align: "left",
    });
    row.items.forEach((item, ci) => {
      s.addText(item, {
        x: col(ci) + 0.08, y: rowY + 0.26, w: colW - 0.16, h: rowH[ri] - 0.26,
        fontSize: 9.5, color: C.dimWhite, valign: "top", fontFace: "Calibri",
      });
    });
    rowY += rowH[ri] + 0.02;
  });

  // Footer
  s.addText("All obstructive shock types: Low CO · High CVP/PAOP · High SVR — differentiated by POCUS window findings above.", {
    x: 0.3, y: 7.15, w: 12.7, h: 0.27,
    fontSize: 9.5, color: C.grey, align: "center", italic: true,
  });
}

// ─── SLIDE 5: Cardiogenic Shock Drill-Down ─────────────────────────────────────
{
  const s = pres.addSlide();
  applyBg(s);
  addHeader(s, "Cardiogenic Shock  —  POCUS Findings & Subtypes", "LV Failure · RV Failure · Mechanical Complication");

  // Red header bar
  s.addShape(pres.ShapeType.roundRect, {
    x: 0.2, y: 0.95, w: 12.9, h: 0.52,
    fill: { color: C.red }, line: { color: C.red }, rectRadius: 0.1,
  });
  s.addText("❤️  CARDIOGENIC SHOCK  —  Low CO · High PAOP · High SVR · Low SvO₂", {
    x: 0.2, y: 0.95, w: 12.9, h: 0.52,
    fontSize: 13, bold: true, color: C.white, align: "center", valign: "middle",
  });

  // Flow: entry → Q branches
  // Entry box
  qBox(s, 4.65, 1.55, 4.0, 0.55, "LV Function Severely Reduced?\n(EF <30%, dilated LV)", C.accent);

  // Arrow YES
  arrow(s, 4.65, 1.82, 3.35, 1.82);
  label(s, 3.7, 1.62, "YES", C.yellow);

  // Box: LV failure confirmed
  s.addShape(pres.ShapeType.roundRect, {
    x: 1.0, y: 1.55, w: 2.3, h: 0.55,
    fill: { color: C.red }, line: { color: C.red }, rectRadius: 0.1,
  });
  s.addText("LV CARDIOGENIC\nSHOCK CONFIRMED", {
    x: 1.0, y: 1.55, w: 2.3, h: 0.55,
    fontSize: 10, bold: true, color: C.white, align: "center", valign: "middle",
  });

  // Arrow NO
  arrow(s, 8.65, 1.82, 9.95, 1.82);
  label(s, 9.15, 1.62, "NO", C.orange);

  // Is RV enlarged?
  qBox(s, 9.95, 1.55, 3.1, 0.55, "RV enlarged (>2/3 LV)?\n+ RV dysfunction?", C.accent);

  // YES → RV failure
  arrow(s, 11.5, 2.1, 11.5, 2.55);
  label(s, 11.56, 2.2, "YES", C.yellow);
  s.addShape(pres.ShapeType.roundRect, {
    x: 10.0, y: 2.55, w: 2.9, h: 0.55,
    fill: { color: C.orange }, line: { color: C.orange }, rectRadius: 0.1,
  });
  s.addText("RV CARDIOGENIC\nSHOCK (RV MI / PE)", {
    x: 10.0, y: 2.55, w: 2.9, h: 0.55,
    fontSize: 10, bold: true, color: C.white, align: "center", valign: "middle",
  });

  // Lung B-lines sub-question
  arrow(s, 2.15, 2.1, 2.15, 2.55);
  qBox(s, 0.75, 2.55, 2.85, 0.55, "B-lines bilateral?\n(Pulmonary edema)", C.accentDark);
  arrow(s, 2.15, 3.1, 2.15, 3.5);

  s.addShape(pres.ShapeType.roundRect, {
    x: 0.75, y: 3.5, w: 2.85, h: 0.55,
    fill: { color: C.blue }, line: { color: C.blue }, rectRadius: 0.1,
  });
  s.addText("Acute Pulmonary Edema\n(Flash Pulm. Edema)", {
    x: 0.75, y: 3.5, w: 2.85, h: 0.55,
    fontSize: 10, bold: true, color: C.white, align: "center", valign: "middle",
  });

  // ── POCUS Findings Table ─────────────────────────────────────────────────
  s.addShape(pres.ShapeType.rect, {
    x: 0.2, y: 4.18, w: 12.9, h: 0.38,
    fill: { color: C.bgLight }, line: { color: C.greyDark },
  });
  s.addText("CARDIOGENIC SHOCK  —  POCUS FINDINGS SUMMARY", {
    x: 0.2, y: 4.18, w: 12.9, h: 0.38,
    fontSize: 11, bold: true, color: C.accent, align: "center", valign: "middle",
  });

  const cgHeaders = ["ECHO Window", "LV Cardiogenic", "RV Cardiogenic", "Hyperdynamic (Distributive - rule out)"];
  const cgRows = [
    ["LV Function",     "EF <30%, dilated LV, WMA",             "Normal or mildly reduced",       "Hyperdynamic, EF >70%"],
    ["RV Size",         "Normal or mildly enlarged",             "RV:LV >0.9, D-sign, McConnell's","Normal or small"],
    ["Pericardium",     "No effusion (unless post-MI rupture)",  "No effusion",                    "No effusion"],
    ["IVC",             "Dilated, non-collapsible",              "Dilated, non-collapsible",       "Collapsible if early sepsis"],
    ["Lung",            "Bilateral B-lines (pulm. edema)",       "A-lines (clear lungs if RV MI)", "A-lines or B-lines"],
    ["Valves",          "Check for acute MR, VSD (post-MI)",     "TR, pulm HTN features",          "Normal"],
  ];

  const colWs = [1.9, 3.3, 3.3, 4.2];
  const colXs = [0.25, 2.18, 5.52, 8.85];
  const rowHh = 0.38;

  cgHeaders.forEach((h, ci) => {
    s.addShape(pres.ShapeType.rect, {
      x: colXs[ci], y: 4.6, w: colWs[ci], h: 0.35,
      fill: { color: C.greyDark }, line: { color: C.bg },
    });
    s.addText(h, {
      x: colXs[ci], y: 4.6, w: colWs[ci], h: 0.35,
      fontSize: 9, bold: true, color: C.white, align: "center", valign: "middle",
    });
  });

  cgRows.forEach((row, ri) => {
    const rowBg = ri % 2 === 0 ? C.bgLight : C.bg;
    row.forEach((cell, ci) => {
      s.addShape(pres.ShapeType.rect, {
        x: colXs[ci], y: 4.97 + ri * rowHh, w: colWs[ci], h: rowHh,
        fill: { color: ci === 0 ? C.greyDark : rowBg }, line: { color: C.greyDark },
      });
      s.addText(cell, {
        x: colXs[ci] + 0.05, y: 4.97 + ri * rowHh, w: colWs[ci] - 0.1, h: rowHh,
        fontSize: ci === 0 ? 9 : 8.5,
        bold: ci === 0,
        color: ci === 0 ? C.accent : C.dimWhite,
        valign: "middle", fontFace: "Calibri",
      });
    });
  });
}

// ─── SLIDE 6: Hypovolemic vs Distributive ──────────────────────────────────────
{
  const s = pres.addSlide();
  applyBg(s);
  addHeader(s, "Hypovolemic vs Distributive Shock  —  POCUS Differentiation", "IVC + Cardiac + Lung Windows");

  // Shared banner
  s.addShape(pres.ShapeType.roundRect, {
    x: 0.2, y: 0.94, w: 12.9, h: 0.5,
    fill: { color: C.bgLight }, line: { color: C.greyDark }, rectRadius: 0.1,
  });
  s.addText("Both have hyperdynamic/normal LV  ·  Differentiated by IVC size, collapsibility, and clinical context", {
    x: 0.2, y: 0.94, w: 12.9, h: 0.5,
    fontSize: 12, color: C.dimWhite, align: "center", valign: "middle", italic: true,
  });

  // Left: Hypovolemic
  s.addShape(pres.ShapeType.roundRect, {
    x: 0.25, y: 1.54, w: 6.05, h: 5.6,
    fill: { color: C.bgLight }, line: { color: C.blue, width: 2 }, rectRadius: 0.15,
  });
  s.addShape(pres.ShapeType.roundRect, {
    x: 0.25, y: 1.54, w: 6.05, h: 0.55,
    fill: { color: C.blue }, line: { color: C.blue }, rectRadius: 0.15,
  });
  s.addShape(pres.ShapeType.rect, {
    x: 0.25, y: 1.84, w: 6.05, h: 0.25,
    fill: { color: C.blue }, line: { color: C.blue },
  });
  s.addText("💧  HYPOVOLEMIC SHOCK", {
    x: 0.25, y: 1.54, w: 6.05, h: 0.55,
    fontSize: 14, bold: true, color: C.white, align: "center", valign: "middle",
  });

  const hypoRows = [
    ["IVC Size",           "SMALL  (<1.5 cm diameter)"],
    ["IVC Collapsibility", "MARKED  (CI >50%)  ✓"],
    ["LV Size/Function",   "Small LV cavity, hyperdynamic EF"],
    ["LV Wall Motion",     "Normal — no WMA"],
    ["Lung Windows",       "A-lines (no pulmonary edema)"],
    ["RV Size",            "Normal or small"],
    ["Pericardium",        "No effusion"],
    ["Clinical Context",   "Trauma, hemorrhage, vomiting,\ndiarrhea, burns, third-spacing"],
    ["Fluid Response",     "Rapid improvement with IVF bolus"],
  ];

  hypoRows.forEach(([k, v], i) => {
    const yy = 2.2 + i * 0.52;
    s.addText(k + ":", {
      x: 0.4, y: yy, w: 2.1, h: 0.45,
      fontSize: 9.5, bold: true, color: C.accent, valign: "middle",
    });
    s.addText(v, {
      x: 2.52, y: yy, w: 3.6, h: 0.45,
      fontSize: 9.5, color: C.dimWhite, valign: "middle",
    });
  });

  // Right: Distributive
  s.addShape(pres.ShapeType.roundRect, {
    x: 6.95, y: 1.54, w: 6.1, h: 5.6,
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    x: 6.95, y: 1.54, w: 6.1, h: 0.55,
    fontSize: 14, bold: true, color: C.white, align: "center", valign: "middle",
  });

  const distRows = [
    ["IVC Size",           "VARIABLE  (often normal/small early)"],
    ["IVC Collapsibility", "VARIABLE or HIGH (after resuscitation: normal)"],
    ["LV Size/Function",   "HYPERDYNAMIC  EF >65–70%  ⚡"],
    ["LV Wall Motion",     "Normal, hyperdynamic — global"],
    ["Lung Windows",       "A-lines early; B-lines if ARDS develops"],
    ["RV Size",            "Normal (unless sepsis-induced RV dysfxn)"],
    ["Pericardium",        "No effusion"],
    ["Clinical Context",   "Fever, infection (sepsis), rash/allergen\n(anaphylaxis), SCI (neurogenic)"],
    ["Vasopressor Need",   "Often high-dose NE required despite\nadequate volume"],
  ];

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}

// ─── SLIDE 7: Distributive Subtypes ───────────────────────────────────────────
{
  const s = pres.addSlide();
  applyBg(s);
  addHeader(s, "Distributive Shock Subtypes  —  POCUS + Clinical Clues", "Septic · Anaphylactic · Neurogenic · Adrenal");

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  s.addText("🔥  All distributive subtypes share: Hyperdynamic LV · Low/Normal IVC · Vasoplegic state — differentiated by clinical triggers", {
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    fontSize: 11, bold: true, color: C.white, align: "center", valign: "middle",
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  const subtypes = [
    {
      icon: "🦠", title: "SEPTIC SHOCK",
      color: C.red,
      echo: "Hyperdynamic LV (early)\nSeptic cardiomyopathy (late): reduced EF",
      ivc: "Variable; small early; normal/dilated after resuscitation",
      lung: "A-lines early; B-lines/consolidation if pneumonia or ARDS",
      extra: "Clinical triggers: Fever >38.3°C or <36°C, tachycardia, hypotension. Lactate >2 mmol/L. Source: lung, abdomen, UTI, line.",
      action: "Blood cultures → broad-spectrum ABx within 1h → 30 mL/kg IVF → NE if MAP <65",
    },
    {
      icon: "⚠️", title: "ANAPHYLACTIC SHOCK",
      color: C.yellow,
      echo: "Hyperdynamic LV. High CO. May see Takotsubo-like pattern (rare). No structural abnormality.",
      ivc: "Small, collapsible IVC (massive capillary leak + vasodilation)",
      lung: "B-lines may appear if bronchospasm + ARDS. Airway edema on soft tissue views.",
      extra: "Clinical triggers: Allergen exposure (food, drug, sting). Urticaria, angioedema, bronchospasm. Rapid onset (<30 min).",
      action: "IM Epinephrine 0.3–0.5 mg (1:1000) STAT → IVF → Diphenhydramine + Steroids",
    },
    {
      icon: "🫀", title: "NEUROGENIC SHOCK",
      color: C.green,
      echo: "Normal or hyperdynamic LV. Normal valves. No effusion. Bradycardia on tracing.",
      ivc: "Variable; often small-normal; responds to IVF",
      lung: "Normal (A-lines). Watch for aspiration if cervical SCI.",
      extra: "Clinical: SCI ≥T6, hypotension + BRADYCARDIA (key!). Skin warm and dry (vasodilation without catecholamines). Poikilothermic.",
      action: "IVF resuscitation → Norepinephrine/Phenylephrine → Atropine for bradycardia. MAP target ≥85 mmHg.",
    },
    {
      icon: "💊", title: "ADRENAL/ENDOCRINE SHOCK",
      color: C.purple,
      echo: "Normal LV function. Occasionally mildly reduced contractility (steroid-responsive).",
      ivc: "Small/collapsible (hypovolemia from aldosterone deficiency causing Na/water loss)",
      lung: "Normal (A-lines). No pulmonary edema.",
      extra: "Clinical: Hypotension refractory to IVF + vasopressors. Hyponatremia, hyperkalemia, hypoglycemia. Eosinophilia. Prior steroid use.",
      action: "Hydrocortisone 100 mg IV bolus → D5NS → Do NOT wait for cortisol result if hemodynamically unstable",
    },
  ];

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    const sections = [
      { label: "ECHO", val: sub.echo },
      { label: "IVC", val: sub.ivc },
      { label: "LUNG", val: sub.lung },
      { label: "TRIGGERS", val: sub.extra },
      { label: "ACTION", val: sub.action },
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}

// ─── SLIDE 8: Quick Reference Summary Card ────────────────────────────────────
{
  const s = pres.addSlide();
  applyBg(s);
  addHeader(s, "Quick Reference  —  POCUS Shock Summary Card", "Bedside reference · All 4 categories");

  // Big table
  const headers = ["SHOCK TYPE", "CARDIAC ECHO", "IVC", "LUNG", "KEY CLUE", "1st ACTION"];
  const tableData = [
    {
      type: "HYPOVOLEMIC", tc: C.blue,
      echo: "Small LV\nHyperdynamic EF",
      ivc: "Small (<1.5 cm)\nCollapsible >50%",
      lung: "A-lines\n(normal)",
      clue: "Trauma, hemorrhage,\ndehydration history",
      action: "Crystalloid/Blood\n30 mL/kg IVF bolus",
    },
    {
      type: "CARDIOGENIC\n(LV)", tc: C.red,
      echo: "Dilated LV\nEF <30%\nWall motion abnl.",
      ivc: "Dilated\nNon-collapsible",
      lung: "B-lines bilateral\n(pulm. edema)",
      clue: "Chest pain, JVD,\nS3, rales, troponin ↑",
      action: "Identify cause\nPCI if STEMI\nNE + Dobutamine",
    },
    {
      type: "CARDIOGENIC\n(RV)", tc: "C06000",
      echo: "RV:LV >0.9\nD-sign\nMcConnell's sign",
      ivc: "Dilated\nNon-collapsible",
      lung: "A-lines\n(clear)",
      clue: "DVT risk, hypoxia,\nSinus tachycardia\nright heart strain ECG",
      action: "UFH → tPA if massive\nCaution with IVF\nNE vasopressor",
    },
    {
      type: "CARDIAC\nTAMPONADE", tc: C.purple,
      echo: "Pericardial effusion\nRV diastolic collapse\nSwinging heart",
      ivc: "Dilated\nNon-collapsible",
      lung: "A-lines\n(normal)",
      clue: "Beck's triad: JVD\n+ muffled sounds\n+ hypotension. Electrical alternans.",
      action: "Pericardiocentesis\nSTAT + IV fluids\nas bridge",
    },
    {
      type: "TENSION PTX", tc: C.green,
      echo: "Hyperdynamic LV\n(RV compressed)",
      ivc: "Variable",
      lung: "ABSENT sliding\nBarcode M-mode\nLung point present",
      clue: "Unilateral: no breath\nsounds + tracheal\ndeviation (late sign)",
      action: "Needle decompression\n2nd ICS MCL\nNO imaging delay",
    },
    {
      type: "SEPTIC\n(Distributive)", tc: C.orange,
      echo: "Hyperdynamic EF\n(early)\nReduced EF (late)",
      ivc: "Small early\nVariable after IVF",
      lung: "A-lines early\nB-lines if ARDS",
      clue: "Fever, infection\nsource. Lactate >2.\nWarm extremities.",
      action: "Cultures → ABx\n→ 30 mL/kg IVF\n→ NE if MAP <65",
    },
    {
      type: "ANAPHYLACTIC\n(Distributive)", tc: C.yellow,
      echo: "Hyperdynamic EF\nHigh CO",
      ivc: "Small + collapsible\n(capillary leak)",
      lung: "B-lines if severe\nbronchospasm/ARDS",
      clue: "Allergen exposure\nUrticaria, angioedema,\nbronchospasm",
      action: "Epinephrine IM\n0.3 mg (1:1000)\nSTAT + IVF",
    },
    {
      type: "NEUROGENIC\n(Distributive)", tc: "2E7D32",
      echo: "Normal or hyper-\ndynamic. No WMA.",
      ivc: "Small-normal\nResponds to IVF",
      lung: "A-lines (normal)\nWatch for aspiration",
      clue: "SCI ≥T6: BRADYCARDIA\n+ hypotension + warm\n dry skin",
      action: "IVF + NE/Phenylephrine\nAtropine if bradycardia\nMAP target ≥85",
    },
  ];

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    const rowBg = ri % 2 === 0 ? C.bgLight : "0F2236";

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      x: cx[0], y: ry, w: cw[0], h: rh,
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      x: cx[0], y: ry, w: cw[0], h: rh,
      fontSize: 9, bold: true, color: C.white, align: "center", valign: "middle",
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        fontSize: 8.5, color: C.dimWhite, valign: "middle", fontFace: "Calibri",
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    fontSize: 9, color: C.grey, align: "center", italic: true,
  });
}

// ─── SLIDE 9: Closing / Key Pearls ────────────────────────────────────────────
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  applyBg(s);

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  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 7.5, fill: { color: C.accent } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 0.12, fill: { color: C.accent } });

  s.addText("Key POCUS Pearls  —  Do Not Miss", {
    x: 0.4, y: 0.2, w: 12.5, h: 0.7,
    fontSize: 26, bold: true, color: C.accent, fontFace: "Calibri",
  });

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    { icon: "1", color: C.red,    text: "TAMPONADE: RV diastolic collapse is the most sensitive echo sign — even a small effusion can cause tamponade if rapid accumulation." },
    { icon: "2", color: C.green,  text: "TENSION PTX: Treat on CLINICAL grounds BEFORE imaging. Needle decompression saves lives in seconds. Absent lung sliding = act now." },
    { icon: "3", color: C.blue,   text: "HYPOVOLEMIA vs DISTRIBUTIVE: Small + collapsible IVC with hyperdynamic LV appears in both. History and lactate distinguish them." },
    { icon: "4", color: C.orange, text: "SEPTIC SHOCK: Look for septic cardiomyopathy (reduced EF) late in sepsis — the LV can fail after initial hyperdynamic phase." },
    { icon: "5", color: C.pink,   text: "MASSIVE PE: McConnell's sign (akinetic RV free wall, spared apex) has high specificity for PE. D-sign = septal shift = obstructive." },
    { icon: "6", color: C.purple, text: "NEUROGENIC SHOCK: The only shock with BRADYCARDIA. Warm skin + bradycardia + SCI history = neurogenic until proven otherwise." },
    { icon: "7", color: C.yellow, text: "MIXED SHOCK: Always possible — e.g. sepsis + cardiac tamponade in cancer; trauma hemorrhage + myocardial contusion. Reassess after each intervention." },
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  s.addText("Sources: Rosen's Emergency Medicine 9e  ·  Barash Clinical Anesthesia 9e  ·  Mulholland & Greenfield's Surgery 7e  ·  ACEP POCUS Guidelines", {
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    fontSize: 9, color: C.greyDark, align: "center",
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// ─── Write file ───────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/shock-pocus-flowchart/POCUS_Shock_Decision_Tree.pptx" })
  .then(() => console.log("✅ DONE: POCUS_Shock_Decision_Tree.pptx"))
  .catch(err => { console.error("ERROR:", err); process.exit(1); });

Running Command

cd /home/daytona/workspace/shock-pocus-flowchart && node build.js 2>&1

Running Command

ls -lh /home/daytona/workspace/shock-pocus-flowchart/

Your decision tree flowchart is ready:

POCUS Shock Decision Tree
Presentation · PPTX
(414 KB, 9 slides)

What's Inside

The presentation uses a deep navy + teal color scheme with color-coded shock types throughout:

Slide	Content
1	Title slide
2	3-Window POCUS Protocol - Cardiac, IVC, and Lung window assessment
3	Master Decision Tree - 5-question sequential flowchart: pericardial effusion → absent lung sliding → RV:LV ratio → LV function → IVC collapsibility → diagnosis
4	Obstructive Shock Drill-Down - Tamponade vs Tension PTX vs Massive PE side-by-side with POCUS findings, differentiators, and immediate actions
5	Cardiogenic Shock Drill-Down - LV vs RV cardiogenic with full comparison table
6	Hypovolemic vs Distributive - Head-to-head panel comparison (IVC, echo, lung, fluid response)
7	Distributive Subtypes - Septic, Anaphylactic, Neurogenic, Adrenal - individual cards with ECHO/IVC/Lung/Triggers/Action
8	Quick Reference Summary Card - Full 8-row × 6-column bedside reference table
9	7 Key POCUS Pearls - Must-not-miss clinical tips

Core decision logic on Slide 3:

Pericardial effusion + RV collapse? → Tamponade
Absent lung sliding (barcode sign)? → Tension PTX
RV:LV >0.9 + D-sign + non-collapsible IVC? → Massive PE
EF <30% + dilated LV? → Cardiogenic shock
IVC small + collapsible (CI >50%)? → Hypovolemic; otherwise → Distributive

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