ls -la /home/daytona/workspace/ 2>/dev/null || echo "workspace empty or missing"

mkdir -p /home/daytona/workspace/anaesthesia-exam && ls /home/daytona/skills/doc…

~/anaesthesia-exam/build_doc.js

const {
  Document, Packer, Paragraph, TextRun, HeadingLevel, AlignmentType,
  PageBreak, BorderStyle, UnderlineType
} = require('docx');
const fs = require('fs');

// Helper functions
const heading1 = (text) => new Paragraph({
  text,
  heading: HeadingLevel.HEADING_1,
  spacing: { before: 400, after: 200 }
});

const heading2 = (text) => new Paragraph({
  text,
  heading: HeadingLevel.HEADING_2,
  spacing: { before: 280, after: 120 }
});

const heading3 = (text) => new Paragraph({
  text,
  heading: HeadingLevel.HEADING_3,
  spacing: { before: 200, after: 80 }
});

const para = (text) => new Paragraph({
  children: [new TextRun({ text, size: 24 })],
  spacing: { before: 80, after: 80 },
  indent: { left: 0 }
});

const bullet = (text, level = 0) => new Paragraph({
  children: [new TextRun({ text, size: 24 })],
  bullet: { level },
  spacing: { before: 40, after: 40 }
});

const bold = (label, text) => new Paragraph({
  children: [
    new TextRun({ text: label, bold: true, size: 24 }),
    new TextRun({ text: ': ' + text, size: 24 })
  ],
  spacing: { before: 60, after: 60 }
});

const tableRow = (label, value) => new Paragraph({
  children: [
    new TextRun({ text: label, bold: true, size: 22 }),
    new TextRun({ text: ' — ' + value, size: 22 })
  ],
  spacing: { before: 40, after: 40 },
  indent: { left: 360 }
});

const pageBreak = () => new Paragraph({ children: [new PageBreak()] });

const titlePage = [
  new Paragraph({
    children: [new TextRun({ text: '', size: 24 })],
    spacing: { before: 600 }
  }),
  new Paragraph({
    children: [new TextRun({
      text: 'ANAESTHESIA EXAMINATION ANSWERS',
      bold: true, size: 44, allCaps: true
    })],
    alignment: AlignmentType.CENTER,
    spacing: { before: 200, after: 200 }
  }),
  new Paragraph({
    children: [new TextRun({
      text: '10 Model Answers for 10-Mark Questions',
      size: 32, italics: true
    })],
    alignment: AlignmentType.CENTER,
    spacing: { before: 100, after: 100 }
  }),
  new Paragraph({
    children: [new TextRun({
      text: 'Based on: Miller\'s Anesthesia 10e | Barash Clinical Anesthesia 9e | Morgan & Mikhail\'s Clinical Anesthesiology 7e',
      size: 22
    })],
    alignment: AlignmentType.CENTER,
    spacing: { before: 100, after: 100 }
  }),
  new Paragraph({
    children: [new TextRun({ text: 'May 2026', size: 24 })],
    alignment: AlignmentType.CENTER,
    spacing: { before: 80, after: 600 }
  }),
  pageBreak()
];

// =================== QUESTION 1 ===================
const q1 = [
  heading1('Q1. Resuscitation in Pregnant Women and Surviving Sepsis Guidelines'),
  heading2('A. Resuscitation in Pregnant Women'),
  heading3('Physiological Considerations'),
  para('Pregnancy causes profound physiological changes that modify resuscitation priorities. By term, cardiac output increases 40–50%, blood volume by 45%, and oxygen consumption by 20%. The gravid uterus causes aortocaval compression when the patient is supine, reducing venous return and cardiac output by up to 30%.'),
  heading3('Key Modifications for Cardiac Arrest in Pregnancy (ACLS adaptations)'),
  bullet('LEFT LATERAL UTERINE DISPLACEMENT (LUD): Manual displacement of the uterus to the left or 15–30° left lateral tilt to relieve aortocaval compression. This is mandatory throughout resuscitation.'),
  bullet('Airway: Higher risk of aspiration (reduced lower oesophageal sphincter tone, increased gastric pressure); rapid sequence intubation (RSI) with cricoid pressure is standard. Smaller ETT (6.0–7.0 mm) recommended due to airway oedema.'),
  bullet('Ventilation: Reduced FRC and increased oxygen consumption → faster desaturation. Pre-oxygenate aggressively. Target SpO₂ ≥ 95%.'),
  bullet('Chest compressions: Standard hand position; compressions may be slightly less effective due to diaphragm elevation.'),
  bullet('Defibrillation: Same energy settings as non-pregnant patient. Remove fetal monitors first.'),
  bullet('Perimortem Caesarean Delivery (PMCD): If ROSC not achieved within 4 minutes of cardiac arrest, delivery should be performed by 5 minutes ("4-minute rule"). Improves maternal venous return and facilitates resuscitation. Neonatal outcomes best when delivered within 5 minutes.'),
  bullet('Reversible causes (H\'s and T\'s): Especially consider amniotic fluid embolism, pulmonary embolism, haemorrhage, pre-eclampsia/eclampsia, local anaesthetic toxicity.'),
  heading3('Drug Modifications'),
  bullet('Vasopressors: Epinephrine is the drug of choice in cardiac arrest. For non-arrest hypotension, phenylephrine or ephedrine preferred (ephedrine crosses placenta less).'),
  bullet('Avoid sodium bicarbonate, magnesium (unless for eclampsia/torsades), and amiodarone relative to alternatives where possible.'),
  heading2('B. Surviving Sepsis Campaign (SSC) Guidelines — Resuscitation'),
  para('The Surviving Sepsis Campaign guidelines (last updated 2021) provide evidence-based bundles for sepsis and septic shock management:'),
  heading3('1-Hour Bundle (Hour-1 Bundle)'),
  bullet('Measure lactate level; remeasure if initial lactate > 2 mmol/L'),
  bullet('Obtain blood cultures before antibiotic administration'),
  bullet('Administer broad-spectrum antibiotics within 1 hour of recognition'),
  bullet('Begin 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L'),
  bullet('Apply vasopressors if hypotensive during or after fluid resuscitation; target MAP ≥ 65 mmHg'),
  heading3('Fluid Resuscitation'),
  bullet('Balanced crystalloids (lactated Ringer\'s/PlasmaLyte) preferred over normal saline (reduces risk of hyperchloraemic acidosis)'),
  bullet('Reassess haemodynamic status after each fluid challenge (dynamic parameters: pulse pressure variation, stroke volume variation, passive leg raise test preferred over static CVP/PCWP)'),
  bullet('Avoid starch solutions (increased AKI and mortality risk)'),
  bullet('Albumin may be used as adjunct when large volumes of crystalloid required'),
  heading3('Vasopressors and Inotropes'),
  bullet('Norepinephrine: First-line vasopressor; target MAP ≥ 65 mmHg'),
  bullet('Vasopressin 0.03–0.04 U/min: Add to norepinephrine to raise MAP or spare norepinephrine dose'),
  bullet('Epinephrine: Add when additional agent required'),
  bullet('Dobutamine: Inotrope for persistent hypoperfusion despite adequate MAP and filling'),
  bullet('Dopamine: Not recommended (higher risk of arrhythmia)'),
  heading3('Antibiotic Therapy'),
  bullet('Broad-spectrum empirical antibiotics within 1 hour; de-escalate guided by cultures and sensitivities'),
  bullet('Duration: 7–10 days typical; procalcitonin-guided de-escalation recommended'),
  heading3('Corticosteroids'),
  bullet('Hydrocortisone 200 mg/day IV: Use if haemodynamic instability persists despite adequate fluids and vasopressors (vasopressor-refractory septic shock)'),
  heading3('Other SSC Recommendations'),
  bullet('Target blood glucose 144–180 mg/dL (8–10 mmol/L); avoid hypoglycaemia'),
  bullet('Lung-protective ventilation: TV 6 mL/kg IBW, plateau pressure < 30 cmH₂O, PEEP titration'),
  bullet('Conservative fluid strategy after initial resuscitation'),
  bullet('Early source control within 6–12 hours'),
  para('Reference: Miller\'s Anesthesia 10e, Chapter 97 (Critical Care Medicine); Surviving Sepsis Campaign Guidelines 2021; Barash Clinical Anesthesia 9e, Chapter 56'),
  pageBreak()
];

// =================== QUESTION 2 ===================
const q2 = [
  heading1('Q2. Liver Function Tests (LFTs) and Their Significance; Child-Pugh Score'),
  heading2('A. Liver Function Tests and Their Significance'),
  heading3('1. Hepatocellular Injury Markers'),
  tableRow('ALT (Alanine aminotransferase)', 'Most specific for hepatocellular injury. Elevated in viral hepatitis, drug-induced liver injury (DILI), NAFLD. Values > 10× ULN suggest acute hepatocellular injury.'),
  tableRow('AST (Aspartate aminotransferase)', 'Less specific; elevated in hepatic and extrahepatic (cardiac, muscle) injury. AST:ALT ratio > 2:1 suggests alcoholic hepatitis.'),
  tableRow('LDH (Lactate dehydrogenase)', 'Non-specific; elevated in massive hepatic necrosis, malignancy, haemolysis.'),
  heading3('2. Cholestasis Markers'),
  tableRow('ALP (Alkaline phosphatase)', 'Elevated in biliary obstruction, infiltrative disease, bone disease. Isoenzymes differentiate source.'),
  tableRow('GGT (Gamma-glutamyl transferase)', 'Sensitive for alcohol use; elevated in cholestasis, fatty liver. Often used to confirm hepatic origin of elevated ALP.'),
  tableRow('Bilirubin (total, direct, indirect)', 'Total > 1.2 mg/dL = hyperbilirubinaemia. Direct (conjugated) elevated in cholestasis/obstruction. Indirect (unconjugated) elevated in haemolysis or impaired conjugation (Gilbert\'s syndrome).'),
  heading3('3. Synthetic Function Markers'),
  tableRow('Prothrombin Time (PT/INR)', 'Reflects synthesis of clotting factors I, II, V, VII, X. Prolonged PT = significant synthetic dysfunction. Most sensitive early marker of acute liver failure.'),
  tableRow('Serum Albumin', 'Half-life ~21 days; reflects chronic synthetic function. Hypoalbuminaemia (< 3.5 g/dL) indicates chronic hepatic insufficiency or malnutrition.'),
  tableRow('Serum Ammonia', 'Elevated in hepatic encephalopathy due to reduced urea cycle activity.'),
  heading3('Anaesthetic Significance of Abnormal LFTs'),
  bullet('Prolonged PT/INR: Increased bleeding risk; FFP, vitamin K, or PCC may be required'),
  bullet('Low albumin: Altered drug binding → increased free fraction of highly protein-bound drugs (e.g., benzodiazepines, propofol, opioids); dose reduction required'),
  bullet('Elevated bilirubin: Risk of hepatorenal syndrome, coagulopathy, impaired drug metabolism'),
  bullet('High AST/ALT: Avoid hepatotoxic agents; halothane absolutely contraindicated; isoflurane/desflurane preferred'),
  bullet('Cirrhotic patients: Reduced pseudocholinesterase → prolonged suxamethonium effect; ascites → altered drug volume of distribution'),
  heading2('B. Child-Pugh Score'),
  para('The Child-Pugh score (Child-Turcotte-Pugh, CTP) classifies severity of chronic liver disease and predicts perioperative mortality risk in patients undergoing surgery.'),
  heading3('Scoring Criteria (1–3 points each parameter)'),
  new Paragraph({
    children: [new TextRun({ text: 'Parameter', bold: true, size: 22 }), new TextRun({ text: '         1 point          2 points          3 points', size: 22 })],
    spacing: { before: 60, after: 40 }
  }),
  tableRow('Bilirubin (μmol/L)', '< 34   |   34–51   |   > 51'),
  tableRow('Albumin (g/dL)', '> 3.5   |   2.8–3.5   |   < 2.8'),
  tableRow('PT prolongation (sec) / INR', '< 4 / < 1.7   |   4–6 / 1.7–2.3   |   > 6 / > 2.3'),
  tableRow('Ascites', 'None   |   Mild/controlled   |   Moderate/refractory'),
  tableRow('Encephalopathy', 'None   |   Grade I–II   |   Grade III–IV'),
  heading3('Classification'),
  tableRow('Class A (5–6 points)', 'Well-compensated disease; perioperative mortality 10%; low anaesthetic risk'),
  tableRow('Class B (7–9 points)', 'Significant dysfunction; perioperative mortality 30%; moderate risk'),
  tableRow('Class C (10–15 points)', 'Decompensated cirrhosis; perioperative mortality 76–82%; elective surgery generally contraindicated'),
  heading3('MELD Score'),
  para('The Model for End-stage Liver Disease (MELD) score uses creatinine, bilirubin, and INR to stratify transplant priority and predict 90-day surgical mortality more accurately than CTP in some settings. MELD > 14 associated with ≥ 50% perioperative mortality for major surgery.'),
  heading3('Anaesthetic Implications'),
  bullet('Preoperative optimisation: Correct coagulopathy, treat ascites, manage encephalopathy, optimise nutrition'),
  bullet('Avoid nephrotoxic agents and NSAIDs (risk of hepatorenal syndrome)'),
  bullet('Avoid prolonged hypotension → ischaemic hepatitis'),
  bullet('Drug metabolism: Reduced CYP450 activity, reduced first-pass metabolism, altered volume of distribution'),
  bullet('Haemodynamic profile of cirrhosis: Hyperdynamic circulation (high CO, low SVR, portal hypertension)'),
  para('Reference: Miller\'s Anesthesia 10e, Chapter 55 (Anesthesia and the Liver); Morgan & Mikhail\'s 7e, Chapter 35'),
  pageBreak()
];

// =================== QUESTION 3 ===================
const q3 = [
  heading1('Q3. USG-Guided Adductor Canal Block and Renal Replacement Therapy'),
  heading2('A. Ultrasound-Guided Adductor Canal Block (ACB)'),
  heading3('Anatomy'),
  para('The adductor canal (Hunter\'s canal) is an aponeurotic tunnel in the mid-thigh, bounded by:'),
  bullet('Anterolaterally: Vastus medialis'),
  bullet('Posteromedially: Adductor longus and adductor magnus'),
  bullet('Anteriorly: Sartorius muscle (forms the roof)'),
  para('Contents: Femoral artery and vein, saphenous nerve, nerve to vastus medialis (from femoral nerve), and branches of the medial femoral cutaneous nerve.'),
  heading3('Mechanism and Effect'),
  bullet('Primarily blocks the SAPHENOUS NERVE (sensory branch of femoral nerve) → provides analgesia to the medial knee, medial leg, and medial ankle'),
  bullet('Nerve to vastus medialis may also be blocked → some motor-sparing effect on quadriceps compared to femoral nerve block'),
  bullet('ACB preserves quadriceps strength (motor-sparing) better than femoral nerve block → earlier mobilisation, reduced fall risk post-TKA'),
  heading3('Indications'),
  bullet('Primary: Total knee arthroplasty (TKA) postoperative analgesia'),
  bullet('ACL reconstruction, medial knee procedures'),
  bullet('Adjunct to spinal anaesthesia for knee surgery'),
  heading3('Ultrasound-Guided Technique'),
  para('Patient position: Supine with hip externally rotated and knee slightly flexed ("frog-leg" position).'),
  bullet('PROBE: High-frequency linear (10–15 MHz) transducer placed transversely on the mid-thigh, one-third distal to the inguinal ligament'),
  bullet('SCANNING: Identify the femoral artery (anechoic pulsatile structure) deep to the sartorius. The saphenous nerve appears as a hyperechoic oval structure lateral to the artery.'),
  bullet('NEEDLE: In-plane or out-of-plane approach. Advance until tip is lateral to the femoral artery within the canal.'),
  bullet('INJECTION: 15–20 mL local anaesthetic (0.25–0.5% bupivacaine or 0.2–0.375% ropivacaine). Confirm spread around the saphenous nerve and femoral artery without entering the vessel.'),
  bullet('NERVE STIMULATION: May be combined to confirm; evokes knee extension (nerve to vastus medialis) or paraesthesia in saphenous distribution.'),
  heading3('Advantages over Femoral Nerve Block'),
  bullet('Motor-sparing: Quadriceps strength preserved, allowing early ambulation and physiotherapy'),
  bullet('Equivalent analgesia for medial knee procedures'),
  bullet('Lower fall risk in postoperative period'),
  heading3('Complications'),
  bullet('Vascular puncture (femoral artery), haematoma'),
  bullet('Nerve injury (rare)'),
  bullet('Local anaesthetic systemic toxicity (LAST)'),
  bullet('Failed block (~5–10% rate)'),
  heading2('B. Renal Replacement Therapy (RRT)'),
  para('RRT is used in ICU/perioperative settings to support or replace renal function in acute kidney injury (AKI) or in patients with end-stage renal disease (ESRD).'),
  heading3('Indications for Initiation (AEIOU mnemonic)'),
  bullet('A — Acidosis: Metabolic acidosis refractory to medical treatment (pH < 7.1)'),
  bullet('E — Electrolytes: Life-threatening hyperkalaemia (K⁺ > 6.5 mEq/L) unresponsive to treatment'),
  bullet('I — Intoxication: Dialysable toxins (methanol, ethylene glycol, salicylates, lithium)'),
  bullet('O — Overload: Diuretic-resistant fluid overload with respiratory compromise'),
  bullet('U — Uraemia: Uraemic encephalopathy, pericarditis, platelet dysfunction (BUN > 100 mg/dL)'),
  heading3('Modalities of RRT'),
  tableRow('Intermittent Haemodialysis (IHD)', '3–4 hours/session; haemodynamically unstable patients tolerate poorly; efficient solute removal'),
  tableRow('Sustained Low-Efficiency Dialysis (SLED)', 'Hybrid: 8–12 hours; better haemodynamic tolerance than IHD'),
  tableRow('Continuous RRT (CRRT)', 'Preferred in ICU/haemodynamically unstable patients; 24 hours/day; CVVH, CVVHD, CVVHDF variants'),
  tableRow('Peritoneal Dialysis (PD)', 'Less efficient; used in paediatrics, no vascular access; avoids anticoagulation'),
  heading3('CRRT Principles'),
  bullet('CVVH (Continuous Venovenous Haemofiltration): Convection-based; large solutes removed; replacement fluid used'),
  bullet('CVVHD (Continuous Venovenous Haemodialysis): Diffusion-based; small solute removal'),
  bullet('CVVHDF: Combination; most efficient'),
  heading3('Anticoagulation for CRRT'),
  bullet('Regional citrate anticoagulation: Preferred; citrate chelates calcium in circuit; calcium supplemented systemically; avoid in severe hepatic failure'),
  bullet('Unfractionated heparin: Target aPTT 45–60 sec (circuit only); systemic anticoagulation risk'),
  bullet('No anticoagulation: In patients with active bleeding or coagulopathy'),
  heading3('Anaesthetic Considerations'),
  bullet('Drug dosing: Water-soluble, low-protein-bound drugs removed by RRT (aminoglycosides, vancomycin, carbapenem); requires post-filter supplementation'),
  bullet('Electrolyte management: Monitor K⁺, Ca²⁺, Mg²⁺, phosphate closely'),
  bullet('Haemodynamic support: CRRT causes continuous volume shifts; vasopressor requirements may change'),
  bullet('Citrate toxicity: Signs include metabolic alkalosis, hypocalcaemia (ionised Ca < 1.0 mmol/L), elevated total:ionised calcium ratio > 2.5'),
  para('Reference: Miller\'s Anesthesia 10e, Chapters 20 (Regional Anaesthesia), 97 (Critical Care); Morgan & Mikhail\'s 7e, Chapters 17 (Kidney), 46 (Critical Care)'),
  pageBreak()
];

// =================== QUESTION 4 ===================
const q4 = [
  heading1('Q4. Types of Labour Analgesia and Pain Pathway in Labour Pain'),
  heading2('A. Pain Pathway in Labour Pain'),
  heading3('First Stage of Labour — Visceral Pain'),
  para('During the first stage, pain arises from uterine contractions and cervical dilatation. Uterine and cervical afferents travel with sympathetic fibres through the uterine and cervical plexuses, entering the spinal cord at T10–L1 via the hypogastric plexus and lumbar sympathetic chain. Nociceptive signals are transmitted via Aδ and C fibres.'),
  bullet('Anatomical pathway: Uterus → paracervical plexus → uterovaginal plexus → inferior hypogastric plexus → lumbar sympathetic chain → T10–L1 dorsal horn'),
  bullet('Character: Diffuse, cramping, poorly localised visceral pain; referred to lower abdomen, groin, and lower back'),
  heading3('Second Stage of Labour — Somatic Pain'),
  para('Descent and delivery of the fetal head causes somatic pain from distension and laceration of the vagina, perineum, and pelvic floor. These afferents are transmitted via the PUDENDAL NERVE (S2–S4).'),
  bullet('Pathway: Perineum/vagina → pudendal nerve → S2–S4 dorsal horn'),
  bullet('Character: Sharp, well-localised, intense somatic pain'),
  heading3('Neurotransmitters and Modulation'),
  bullet('Primary afferents release: Substance P, CGRP, glutamate at the dorsal horn'),
  bullet('Wind-up phenomenon: Repeated stimulation sensitises spinal neurons (NMDA receptor activation)'),
  bullet('Descending modulation: Endogenous opioid system, noradrenergic pathways (exploited by epidural opioids and clonidine)'),
  heading2('B. Types of Labour Analgesia'),
  heading3('1. Regional Techniques (Gold Standard)'),
  bold('Epidural Analgesia', 'Most effective method; provides complete analgesia for first and second stages'),
  bullet('Technique: Epidural catheter placed at L2–L3 or L3–L4; test dose (lidocaine 45 mg + epinephrine 15 μg); loading dose of 0.0625–0.1% bupivacaine + fentanyl 2 μg/mL; maintenance via PCEA or continuous infusion'),
  bullet('Advantages: Titratable, can be extended for CS; no sedation of neonate'),
  bullet('Complications: Hypotension (treat with fluid preload and ephedrine/phenylephrine), dural puncture headache, motor block, failure rate 5–15%, total spinal, epidural haematoma/abscess (rare)'),
  bold('Combined Spinal-Epidural (CSE)', 'Rapid onset intrathecal component (bupivacaine 2.5 mg + fentanyl 25 μg) + epidural catheter for maintenance; "walking epidural"'),
  bold('Continuous Spinal Analgesia', 'Used in morbid obesity or after accidental dural puncture; intrathecal catheter; risk of high/total spinal'),
  heading3('2. Systemic Opioid Analgesia'),
  bullet('Pethidine (meperidine) 25–50 mg IV/IM: Historically common; neonatal respiratory depression (active metabolite norpethidine); less preferred currently'),
  bullet('Fentanyl 25–50 μg IV boluses or PCIA: Faster onset, shorter duration, less neonatal effect than pethidine; may cause maternal sedation'),
  bullet('Remifentanil PCIA: 0.2–0.4 μg/kg boluses; rapid onset/offset; best systemic option; requires 1:1 midwife monitoring due to maternal apnoea risk; SpO₂ monitoring mandatory'),
  bullet('Morphine: Not preferred in labour due to long duration and active metabolites causing neonatal CNS depression'),
  heading3('3. Nitrous Oxide (Entonox 50% N₂O/O₂)'),
  bullet('Inhaled analgesia; self-administered via demand valve; rapid onset/offset'),
  bullet('Reduces anxiety; mild analgesia only; no neonatal depression'),
  bullet('Limitations: Nausea, dizziness, requires cooperation; environmental pollution; B12 inactivation with prolonged use'),
  heading3('4. Non-Pharmacological Methods'),
  bullet('TENS (Transcutaneous Electrical Nerve Stimulation): Activates Aβ fibres → gate control theory; reduces opioid requirement'),
  bullet('Hydrotherapy (water birth/bath): Warmth reduces muscle spasm and anxiety'),
  bullet('Psychological support, breathing techniques (Lamaze), hypnobirthing'),
  bullet('Acupuncture: Some evidence for reducing pain perception'),
  heading3('5. Other Regional Techniques'),
  bullet('Paracervical block: Blocks T10–L1 afferents at the paracervical ganglia; risk of fetal bradycardia (3–10%); rarely used'),
  bullet('Pudendal nerve block: Bilateral; blocks S2–S4 perineal pain; used for second stage/instrumental delivery; 10 mL 1% lidocaine each side via transvaginal approach'),
  bullet('Lumbar sympathetic block: Blocks first-stage visceral pain; rarely used now'),
  para('Reference: Morgan & Mikhail\'s Clinical Anesthesiology 7e, Chapter 41 (Obstetric Anesthesia); Barash Clinical Anesthesia 9e, Chapter 38 (Obstetric Anesthesia); Miller\'s Anesthesia 10e, Chapter 77'),
  pageBreak()
];

// =================== QUESTION 5 ===================
const q5 = [
  heading1('Q5. Anaesthetic Challenges and Management of Posterior Fossa Tumour'),
  heading2('Anatomical and Pathological Background'),
  para('The posterior fossa (infratentorial compartment) contains the cerebellum, brainstem (midbrain, pons, medulla), cranial nerves IV–XII, and the fourth ventricle. Common tumours: meningioma, acoustic neuroma (vestibular schwannoma), medulloblastoma (children), ependymoma, haemangioblastoma, and metastases. Tumours may cause obstructive hydrocephalus (by compressing the fourth ventricle and CSF outflow), brainstem compression, and cranial nerve deficits.'),
  heading2('Anaesthetic Challenges'),
  heading3('1. Raised Intracranial Pressure (ICP)'),
  bullet('Hydrocephalus from CSF pathway obstruction → ICP elevation'),
  bullet('Risk of tentorial or tonsillar herniation during induction or positioning'),
  bullet('Preoperative VP shunt or external ventricular drain (EVD) may be required'),
  heading3('2. Positioning Hazards'),
  para('Surgery performed in sitting (beach chair), prone, lateral, or park bench position. The SITTING POSITION is preferred for midline posterior fossa tumours (best surgical access, improved venous drainage) but carries unique risks:'),
  bullet('Venous Air Embolism (VAE): Open venous sinuses entrain air; incidence up to 40–60% in sitting craniotomy. Detected by: precordial Doppler (most sensitive), TEE, ETN₂ (most specific), ETco₂ decrease, PA pressure rise.'),
  bullet('Treatment of VAE: Notify surgeon (flood field with saline, occlude entry point), cease N₂O, 100% O₂, left lateral Trendelenburg, aspiration via right heart catheter, vasopressors for hypotension, CPR if cardiac arrest'),
  bullet('Paradoxical Air Embolism (PAE): Air crosses to arterial side via PFO (present in 25–35% of adults) → cerebral or coronary embolism; pre-screen with bubble echocardiography'),
  bullet('Pneumocephalus: Air enters cranial vault; tension pneumocephalus if N₂O used → avoid N₂O in sitting craniotomy'),
  bullet('Macroglossia: Prolonged sitting position with neck flexion → venous/lymphatic obstruction; ensure 2–3 finger breadth between chin and chest'),
  bullet('Haemodynamic instability: Venous pooling in legs → decreased venous return and hypotension; use compression stockings and arterial line for continuous BP monitoring'),
  bullet('Quadriplegia risk: Excessive neck flexion → spinal cord compression at foramen magnum'),
  heading3('3. Brainstem Manipulation'),
  bullet('Surgical manipulation of brainstem → sudden changes in HR, BP, respiration (Cushing response: hypertension + bradycardia)'),
  bullet('Cranial nerve monitoring: Requires avoidance of neuromuscular blockade for facial nerve (CN VII), and may require total intravenous anaesthesia (TIVA) for intraoperative neurophysiological monitoring (IONM)'),
  heading3('4. Obstructive Hydrocephalus'),
  bullet('Acute decompensation risk during anaesthesia induction'),
  bullet('Pre-operative EVD or elective VP shunting may be required for severe hydrocephalus'),
  heading3('5. Emergence and Postoperative'),
  bullet('Cerebellar/brainstem oedema → airway and swallowing dysfunction; may require postoperative ventilation'),
  bullet('Posterior fossa syndrome (especially in children post-medulloblastoma): Mutism, cerebellar dysfunction, emotional lability — occurs 1–5 days post-surgery'),
  heading2('Anaesthetic Management'),
  heading3('Preoperative'),
  bullet('Assess degree of ICP elevation; CT/MRI review for hydrocephalus, brainstem compression, and tumour vascularity'),
  bullet('Steroid therapy: Dexamethasone 4–8 mg IV 6-hourly to reduce vasogenic oedema; start 24–48 hours preoperatively'),
  bullet('Anticonvulsants if seizure history'),
  bullet('Screen for PFO with contrast echocardiography if sitting position planned'),
  bullet('Premedication: Avoid sedatives in elevated ICP; anxiolytics (midazolam small dose) only if ICP controlled'),
  heading3('Induction'),
  bullet('Aim: Smooth induction, avoid ICP spikes, prevent coughing/straining on laryngoscopy'),
  bullet('Propofol (1.5–2 mg/kg) + fentanyl 2–3 μg/kg + lidocaine 1.5 mg/kg IV (attenuates intubation response)'),
  bullet('Suxamethonium: Avoided in chronic neurological deficit (hyperkalaemia risk); rocuronium preferred'),
  bullet('Avoid ketamine (increases CMRO₂ and ICP)'),
  heading3('Maintenance'),
  bullet('TIVA (propofol + remifentanil) preferred when IONM required (evoked potentials, cranial nerve monitoring); volatile agents reduce amplitude of MEPs/SSEPs'),
  bullet('If volatile used: Isoflurane or sevoflurane ≤ 0.5 MAC with N₂O avoided (pneumocephalus, VAE risk)'),
  bullet('Mild hyperventilation: Target PaCO₂ 35–40 mmHg (avoid hypocarbia < 30 mmHg → cerebral ischaemia)'),
  bullet('Head elevation 15–30°; avoid jugular venous compression'),
  bullet('Mannitol 0.25–1 g/kg or hypertonic saline (3% NaCl 100–200 mL) for ICP spikes'),
  bullet('Normoglycaemia: Target glucose 140–180 mg/dL; avoid both hyperglycaemia and hypoglycaemia'),
  heading3('Positioning (Sitting)'),
  bullet('Precordial Doppler over right heart, precordial ETN₂ monitor, right heart catheter (multi-orifice CVP in right atrium for air aspiration)'),
  bullet('Neck position: No more than 2 finger breadths between chin and sternum'),
  bullet('MAST/compression stockings; elevate legs slowly'),
  heading3('Emergence and Postoperative'),
  bullet('Smooth emergence: Avoid coughing, straining; IV lidocaine 1.5 mg/kg before extubation'),
  bullet('If airway reflexes compromised → delayed extubation, ICU admission'),
  bullet('Control PONV aggressively (ondansetron ± dexamethasone); vomiting raises ICP'),
  bullet('Pain: IV paracetamol, opioids judiciously; avoid NSAIDs (bleeding risk in neurosurgery)'),
  para('Reference: Miller\'s Anesthesia 10e, Chapter 57 (Neuroanesthesia); Barash Clinical Anesthesia 9e, Chapter 30; Morgan & Mikhail\'s 7e, Chapter 26 (Neuroanesthesia)'),
  pageBreak()
];

// =================== QUESTION 6 ===================
const q6 = [
  heading1('Q6. Airway Management of Maxillofacial Trauma and Manual Inline Stabilisation (MILS)'),
  heading2('A. Airway Management in Maxillofacial Trauma'),
  heading3('Unique Challenges'),
  bullet('Haemorrhage: Active bleeding into airway from facial fractures, nasal fractures, tongue lacerations → blood, clots, secretions obstruct view'),
  bullet('Oedema: Rapidly progressive soft tissue swelling → airway narrowing; worse over hours post-injury'),
  bullet('Disrupted anatomy: Le Fort fractures (I, II, III), mandibular fractures, palatal fractures → mobile or unstable facial bones; loss of normal anatomical landmarks'),
  bullet('Foreign bodies: Fractured teeth, dentures, food'),
  bullet('Trismus: Pain-related or masseter spasm → restricted mouth opening'),
  bullet('Associated cervical spine injury: Present in up to 10% of blunt facial trauma → MILS required'),
  bullet('Full stomach: Trauma patient → aspiration risk; rapid sequence intubation indicated'),
  heading3('Airway Assessment — Primary Survey'),
  para('Follow ATLS/ABCDE approach. Look for:'),
  bullet('Agitation (hypoxia), gurgling (fluid), stridor (obstruction), hoarse voice (laryngeal trauma)'),
  bullet('Facial symmetry, swelling, ecchymosis, subcutaneous emphysema (laryngotracheal injury)'),
  bullet('Mouth opening, interincisor gap (< 3 cm suggests difficult laryngoscopy)'),
  heading3('Airway Management Strategy'),
  para('Always have a "PLAN A → PLAN B → PLAN C → PLAN D" framework (DAS guidelines):'),
  bold('Plan A', 'RSI + direct laryngoscopy. Preoxygenate with BVM or HFNO. Videolaryngoscopy (VL) as first-line or backup for anticipated difficult airway. Bougie insertion if grade III–IV view.'),
  bold('Plan B', 'Supraglottic Airway Device (SGA): LMA or i-gel as bridge while optimising → not suitable if mouth opening severely restricted or oral injury precludes SGA placement.'),
  bold('Plan C', 'Awake Fibreoptic Intubation (AFOI): Gold standard for anticipated difficult airway when patient is cooperative and haemodynamically stable. Topicalise with lidocaine spray (10%), sedation with dexmedetomidine or ketamine-midazolam. Nasal route if oral access compromised (nasal FOI); avoid nasal intubation in suspected cribriform plate fracture (risk of intracranial tube placement).'),
  bold('Plan D', 'Surgical airway: Emergency cricothyrotomy (scalpel-bougie-tube technique) → Surgical tracheostomy (semi-elective). Elective awake tracheostomy preferred in anticipated impossible mask ventilation + intubation.'),
  heading3('Specific Considerations'),
  bullet('Le Fort III fractures: Floating face, craniofacial separation — nasal intubation absolutely contraindicated'),
  bullet('Mandibular fractures: Bilateral parasymphysis fractures → posterior tongue displacement → acute obstruction; jaw thrust or oral airway aids temporization'),
  bullet('Penetrating neck trauma: Zone I–III injuries; risk of vascular disruption, expanding haematoma → airway displacement; early intubation before obstruction'),
  bullet('Tracheobronchial injury: Avoid positive pressure ventilation until controlled if suspected tracheal tear'),
  heading2('B. Manual Inline Stabilisation (MILS)'),
  heading3('Rationale'),
  para('Cervical spine injury (CSI) must be assumed in all unconscious trauma patients and in those with facial or head injury until excluded radiologically. MILS reduces motion of the unstable cervical spine during laryngoscopy and intubation, minimising the risk of secondary spinal cord injury.'),
  heading3('MILS Technique'),
  bullet('REMOVAL of cervical collar: The front of the collar is removed before intubation attempt (collar restricts mouth opening and worsens laryngoscopic view); MILS replaces collar function'),
  bullet('ASSISTANT position: Kneel or stand facing patient\'s head; grasp the mastoid processes bilaterally with fingertips and the occiput with the palms; forearms resting on the patient\'s shoulders or clavicles for stability'),
  bullet('NEUTRAL POSITION: Maintain head-neck-spine in neutral inline alignment throughout; no extension, flexion, or rotation'),
  bullet('NOT a traction force: MILS is stabilisation, not traction; applying axial traction is dangerous'),
  heading3('Limitations of MILS'),
  bullet('MILS worsens laryngoscopic view (restricts neck extension → Cormack-Lehane grade worsens by 1–2 grades in 22% of cases)'),
  bullet('Videolaryngoscopy (e.g., C-MAC, McGrath) is preferred with MILS — better glottic view without requiring extension'),
  bullet('Trained assistant is mandatory throughout the intubation'),
  heading3('RSI with MILS Protocol Summary'),
  bullet('Preoxygenate 3–5 min (HFNO if available)'),
  bullet('Pre-oxygenation position: 20° reverse Trendelenburg (improves FRC)'),
  bullet('Remove front of hard collar; apply MILS'),
  bullet('Rapid sequence induction: Propofol 1.5 mg/kg or ketamine 1.5 mg/kg (ketamine preferred if haemodynamically unstable) + suxamethonium 1.5 mg/kg or rocuronium 1.2 mg/kg'),
  bullet('Cricoid pressure (controversial): Apply 30 N; release if it impairs view or ventilation'),
  bullet('Videolaryngoscopy first line; have bougie ready; surgical airway team on standby'),
  bullet('Confirm ETT position: EtCO₂ capnography (gold standard) + CXR'),
  para('Reference: Miller\'s Anesthesia 10e, Chapter 44 (Airway Management); Barash Clinical Anesthesia 9e, Chapter 29 (Trauma Anesthesia); Morgan & Mikhail\'s 7e, Chapter 19 (Airway Management)'),
  pageBreak()
];

// =================== QUESTION 7 ===================
const q7 = [
  heading1('Q7. Anaesthesia Management of a 2-Year-Old Child with Foreign Body Insertion — Emergency'),
  heading2('Clinical Scenario'),
  para('A 2-year-old child presenting for emergency removal of an inhaled or ingested foreign body (most commonly a tracheobronchial or oesophageal foreign body). The most common site for airway foreign body (FB) in toddlers is the right main bronchus (wider, more vertical). Common objects: peanuts, toy parts, coins (oesophageal). Presents with choking, respiratory distress, stridor, wheeze, drooling (oesophageal), or dysphonia.'),
  heading2('Preoperative Assessment'),
  heading3('History and Examination'),
  bullet('Time of ingestion and last meal (full stomach → aspiration risk)'),
  bullet('Location of FB: Airway (stridor, wheeze, respiratory distress) vs. oesophageal (drooling, dysphagia, neck pain)'),
  bullet('CXR/lateral neck X-ray: Opacity (radiopaque FB), air-trapping, mediastinal shift, atelectasis'),
  bullet('CT chest/neck if plain X-ray inconclusive and child stable'),
  bullet('Weight (2 years ≈ 12–14 kg), IV access status, fasting status'),
  heading3('Anaesthetic Challenges in This Patient'),
  bullet('FULL STOMACH: Emergency → aspiration risk; balance between RSI (risk of FB displacement with suxamethonium fasciculations) and controlled inhalational induction'),
  bullet('SHARED AIRWAY: Surgeon and anaesthetist compete for the same airway during rigid bronchoscopy/oesophagoscopy'),
  bullet('SMALL AIRWAY: Paediatric airway narrowest at subglottis → FB may cause complete obstruction if dislodged'),
  bullet('HAEMODYNAMIC RESERVE: Limited in small children; hypoxia develops faster due to higher O₂ consumption (6 mL/kg/min vs 3 mL/kg/min in adults) and reduced FRC'),
  bullet('SPONTANEOUS VENTILATION vs CONTROLLED: Debate exists; many prefer spontaneous breathing technique (prevents positive pressure from pushing FB deeper); controlled ventilation used for rigid bronchoscopy'),
  heading2('Anaesthetic Management'),
  heading3('Preparation'),
  bullet('Paediatric emergency trolley with age-appropriate equipment: Paediatric laryngoscopes (Miller blade size 1–1.5 for 2-year-old), Storz ventilating bronchoscope (size 3.5 for 2-year-old), ETT (uncuffed 4.5 mm or cuffed 4.0 mm), video laryngoscope'),
  bullet('Suction × 2 (airway and oesophagus), LMA size 1.5–2, difficult airway cart'),
  bullet('Emergency drugs calculated per weight: Adrenaline 0.01 mg/kg, atropine 0.02 mg/kg, suxamethonium 2 mg/kg, rocuronium 1.2 mg/kg'),
  bullet('IV access: At least 1 large-bore IV; inhalational induction acceptable if no IV'),
  bullet('Full monitoring: SpO₂, EtCO₂, NIBP, ECG, temperature'),
  heading3('Induction'),
  para('For suspected AIRWAY foreign body:'),
  bullet('INHALATIONAL INDUCTION preferred: Sevoflurane 8% in 100% O₂ via face mask; maintains spontaneous ventilation; IV inserted once asleep'),
  bullet('Deepening: Propofol 1–2 mg/kg IV for IV access. Or continue inhalational with sevoflurane until deep plane for airway manipulation'),
  bullet('Topical lidocaine spray (3–4 mg/kg maximum) on vocal cords before bronchoscopy to ablate laryngospasm'),
  bullet('Dexamethasone 0.15 mg/kg IV: Reduces post-instrumentation subglottic oedema'),
  bullet('Avoid suxamethonium initially if foreign body airway (fasciculations may dislodge FB) — use only if laryngospasm occurs'),
  para('For suspected OESOPHAGEAL foreign body (stable child):'),
  bullet('RSI acceptable: Modified RSI with cricoid pressure, rocuronium 1.2 mg/kg + propofol/ketamine'),
  heading3('Maintenance'),
  bullet('Rigid bronchoscopy: Apnoeic oxygenation + intermittent manual ventilation via side port of bronchoscope; TIVA with propofol + remifentanil infusion'),
  bullet('Spontaneous breathing technique: Sevoflurane + remifentanil; surgeon proceeds during preserved respiratory effort'),
  bullet('Oesophagoscopy: Standard IPPV via ETT; TIVA or volatile'),
  heading3('Complications to Anticipate'),
  bullet('Laryngospasm: 4% lidocaine spray, deepen anaesthesia; if complete → suxamethonium 2 mg/kg, reintubate'),
  bullet('Bronchospasm: Deepen anaesthesia, salbutamol via ETT'),
  bullet('Hypoxia: Desaturation during bronchoscopy → withdraw bronchoscope, BMV with 100% O₂, then retry'),
  bullet('FB displacement to opposite bronchus: Surgeon may need to retrieve under fluoroscopy'),
  bullet('Post-obstructive pulmonary oedema: CPAP, furosemide if necessary'),
  heading3('Extubation and Recovery'),
  bullet('Awake extubation when protective reflexes return (swallowing, eye opening)'),
  bullet('Post-extubation monitoring for stridor (subglottic oedema) in PICU/HDU'),
  bullet('Nebulised adrenaline (1:1000, 0.5 mL/kg, max 5 mL) for post-extubation stridor'),
  bullet('Dexamethasone continued 8-hourly × 3 doses'),
  para('Reference: Smith\'s Anesthesia for Infants and Children 9e; Miller\'s Anesthesia 10e, Chapter 93 (Paediatric Anaesthesia); Morgan & Mikhail\'s 7e, Chapter 42 (Paediatric Anaesthesia)'),
  pageBreak()
];

// =================== QUESTION 8 ===================
const q8 = [
  heading1('Q8. Biochemical Changes of Stored Blood, Indications and Complications of Blood Transfusion'),
  heading2('A. Biochemical Changes of Stored Blood (Storage Lesion)'),
  para('Blood stored in standard additive solution (AS-1/SAGM/CPDA-1) at 1–6°C undergoes progressive biochemical deterioration. These "storage lesions" affect red cell viability and function, and become clinically significant when massive transfusion is required.'),
  heading3('Progressive Changes Over Storage'),
  tableRow('pH', 'Decreases from 7.4 to < 7.0 by day 42 due to lactic acid accumulation from continued glycolysis'),
  tableRow('2,3-Diphosphoglycerate (2,3-DPG)', 'Depleted by day 7 → Left shift of O₂-Hb dissociation curve → Increased Hb-O₂ affinity → Impaired tissue oxygen delivery (corrects within 24–48 h of transfusion)'),
  tableRow('Potassium (K⁺)', 'Rises from ~4 mEq/L to 20–30+ mEq/L by day 42 due to K⁺ leak from RBCs (Na-K-ATPase fails at 4°C) → Risk of hyperkalaemia, especially in neonates and rapid transfusion'),
  tableRow('Sodium (Na⁺)', 'Decreases as K⁺ rises; intracellular Na⁺ accumulates (pump failure)'),
  tableRow('Glucose', 'Consumed by RBC glycolysis; added dextrose in storage solutions partially compensates'),
  tableRow('Lactate', 'Accumulates from anaerobic glycolysis → contributes to acidosis'),
  tableRow('Ammonia', 'Rises from amino acid catabolism → concern in hepatic failure patients'),
  tableRow('Microparticles', 'Increase over time; may activate coagulation, cause microvascular obstruction'),
  tableRow('RBC deformability', 'Decreases due to membrane changes → impaired microcirculatory flow'),
  tableRow('Haemolysis', 'Free Hb levels rise with age → contributes to NO scavenging, vasoconstriction, renal toxicity'),
  tableRow('Citrate', 'Anticoagulant present in storage solution; metabolised by liver → hypocalcaemia in massive transfusion'),
  tableRow('Temperature', 'Cold stored at 1–6°C → contributes to hypothermia in massive transfusion; use blood warmer'),
  heading3('Summary Table of Key Changes at Different Intervals'),
  tableRow('Day 1–7', 'Mild acidosis, 2,3-DPG begins declining, minimal K⁺ rise'),
  tableRow('Day 7–21', 'Significant 2,3-DPG depletion, K⁺ rises to 10–15 mEq/L, RBC deformability decreased'),
  tableRow('Day 21–42', 'Severe storage lesions; K⁺ > 20 mEq/L; pH < 7.0; significant haemolysis; MTP situations demand fresh blood when available'),
  heading2('B. Indications for Blood Transfusion'),
  heading3('Red Cell Transfusion (pRBC) Indications'),
  bullet('Haemoglobin-based threshold: Hb < 7 g/dL in stable non-cardiac patients (TRICC trial supports this threshold); Hb < 8 g/dL in patients with cardiovascular disease or post-cardiac surgery'),
  bullet('Acute haemorrhagic shock: Classes III and IV (estimated blood loss > 30% circulating volume, haemodynamic instability)'),
  bullet('Symptomatic anaemia: Angina, heart failure, haemodynamic compromise despite Hb > 7'),
  bullet('Perioperative: Intraoperative Hb < 7–8 g/dL depending on patient reserve, anticipated blood loss'),
  bullet('Sickle cell crisis: Pre-operative exchange transfusion to maintain HbS < 30%'),
  heading3('Fresh Frozen Plasma (FFP) Indications'),
  bullet('Active bleeding with coagulopathy (INR > 1.5 or PT > 1.5× normal)'),
  bullet('Massive transfusion protocol (MTP): 1:1:1 ratio with pRBC and platelets'),
  bullet('Reversal of warfarin in emergency bleeding (when PCC unavailable)'),
  bullet('Thrombotic thrombocytopenic purpura (TTP)'),
  bullet('Coagulation factor deficiencies without specific factor concentrate'),
  heading3('Platelet Transfusion Indications'),
  bullet('Platelet count < 10,000/μL regardless of bleeding (prophylactic)'),
  bullet('< 50,000/μL with active bleeding or invasive procedure'),
  bullet('< 100,000/μL for neurosurgery or ophthalmic surgery'),
  bullet('Massive transfusion (MTP): 1:1:1 ratio'),
  heading3('Cryoprecipitate Indications'),
  bullet('Hypofibrinogenaemia (fibrinogen < 1.5–2.0 g/L) with active bleeding'),
  bullet('Massive haemorrhage — fibrinogen first to deplete'),
  bullet('von Willebrand disease (when desmopressin/vWF concentrate unavailable), haemophilia A (when Factor VIII concentrate unavailable)'),
  heading2('C. Complications of Blood Transfusion'),
  heading3('Immunological / Acute'),
  tableRow('Acute Haemolytic Transfusion Reaction (AHTR)', 'ABO incompatibility (most lethal; clerical error most common cause); fever, flank pain, haemoglobinuria, DIC, acute renal failure; STOP transfusion immediately, aggressive IV fluids, maintain urine output > 1 mL/kg/h, treat DIC'),
  tableRow('Febrile Non-Haemolytic Reaction (FNHTR)', 'Most common reaction; cytokines from donor WBCs; fever ± chills; treat with paracetamol; transfusion may continue'),
  tableRow('Allergic/Anaphylactic', 'IgE-mediated; urticaria to anaphylaxis; treat with antihistamine/adrenaline; stop transfusion'),
  tableRow('Transfusion-Related Acute Lung Injury (TRALI)', '2nd leading cause of transfusion death; non-cardiogenic pulmonary oedema within 6 hours; donor anti-HLA antibodies activate neutrophils; supportive ventilation (lung-protective)'),
  tableRow('Transfusion-Associated Circulatory Overload (TACO)', 'Cardiogenic pulmonary oedema; diurese, slow transfusion rate; distinguish from TRALI by BNP/clinical features'),
  heading3('Metabolic (Massive Transfusion)'),
  tableRow('Hypothermia', 'Cold stored blood → use blood warmer (e.g., Level 1, Ranger)'),
  tableRow('Hypocalcaemia', 'Citrate chelates Ca²⁺; give CaCl₂ 10 mg/kg or Ca gluconate 30 mg/kg per 4 units pRBC in massive transfusion'),
  tableRow('Hyperkalaemia', 'Stored blood K⁺ release; dangerous in neonates/rapid transfusion; use fresh blood (< 7 days) for neonates'),
  tableRow('Dilutional coagulopathy', 'Dilution of clotting factors and platelets; use MTP 1:1:1 + cryoprecipitate'),
  tableRow('Metabolic alkalosis', 'Citrate metabolism generates bicarbonate post-resuscitation'),
  heading3('Infectious'),
  tableRow('Transfusion-Transmitted Infections', 'HIV, HCV, HBV (all screened; risk now < 1:1,000,000 per unit); Bacterial contamination (platelets highest risk; room temperature stored); Parasites (malaria, Babesia, Chagas) in endemic areas'),
  heading3('Other'),
  tableRow('Iron Overload', 'In chronically transfused patients (thalassaemia, sickle cell); treat with deferoxamine chelation'),
  tableRow('Immunomodulation (TRIM)', 'Transfusion-related immunomodulation → theoretically increases infection and cancer recurrence risk; leucodepletion reduces TRIM'),
  para('Reference: Miller\'s Anesthesia 10e, Chapter 49 (Transfusion Medicine); Barash Clinical Anesthesia 9e, Chapter 22 (Haemostasis and Blood Component Therapy); Morgan & Mikhail\'s 7e, Chapter 21'),
  pageBreak()
];

// =================== QUESTION 9 ===================
const q9 = [
  heading1('Q9. Link 25 and Electrical Safety in the Operating Theatre (OT)'),
  heading2('A. Electrical Basics Relevant to OT Safety'),
  heading3('Types of Current'),
  bullet('AC (Alternating Current): Standard mains supply (50–60 Hz); more dangerous than DC at same voltage because low-frequency AC (< 100 Hz) causes sustained muscle tetany and ventricular fibrillation'),
  bullet('DC (Direct Current): Used in defibrillators; less likely to cause VF at same energy'),
  bullet('Macroshock: Current applied to skin surface; current path through body; requires 100–300 mA AC to cause VF'),
  bullet('Microshock: Current applied directly to heart (via intracardiac catheter); as little as 10–100 μA can cause VF — critical concern in electrically susceptible patients'),
  heading3('Electrical Hazards in the OT'),
  bullet('Burns: From current concentration at small contact areas (electrosurgery return plate, ECG electrodes under diathermy)'),
  bullet('Electrocution: Macroshock from faulty equipment, poor earthing'),
  bullet('Ignition: Electrical sparks igniting anaesthetic gases (especially cyclopropane, diethyl ether) — now less relevant with modern agents, but still risk with oxygen-enriched atmospheres'),
  bullet('EMI (Electromagnetic Interference): Diathermy interfering with pacemakers, implantable defibrillators, IONM equipment'),
  heading2('B. Isolation Transformer and the IT System'),
  para('The OT electrical system uses an ISOLATED (IT — insulation technique) power supply to prevent grounding hazards:'),
  bullet('Standard hospital power is line-isolated from earth: One fault (single fault) does NOT complete an earth-grounded circuit → patient not at risk from single insulation failure'),
  bullet('LINE ISOLATION MONITOR (LIM): Continuously monitors leakage current between the isolated supply and earth. Alarms when leakage exceeds safe limit (typically 2 mA).'),
  bullet('When LIM alarms: Indicates first fault has occurred → identify and remove faulty equipment sequentially; a second fault would complete the circuit and cause shock/injury'),
  heading2('C. Link 25 (Line Isolation Monitor — LIM System)'),
  para('The term "LINK 25" historically refers to the line isolation monitor alarm that activates when total current leakage from the isolated power supply to ground reaches 2 mA or more. This is the point at which the isolated power system\'s safety margin is breached.'),
  heading3('When Link 25 / LIM Alarms'),
  bullet('Do NOT immediately switch off critical equipment (e.g., anaesthetic machine, surgical diathermy in use) — this may endanger the patient'),
  bullet('Systematically unplug non-essential electrical equipment one at a time; after each unplugging, observe if alarm resets → the last device unplugged before alarm reset is the fault source'),
  bullet('Remove the faulty device and have it inspected by biomedical engineering before use'),
  bullet('Procedure can continue safely after fault identified and removed (single fault environment safe in IT system)'),
  heading3('Electrosurgery (Diathermy) Safety'),
  bullet('Monopolar diathermy: High-frequency AC current (300 kHz–3 MHz) causes tissue cutting and coagulation; return electrode plate must have good contact to prevent burns at plate site (current concentration)'),
  bullet('Bipolar diathermy: Current flows only between the two forceps tips; much safer; no return plate required; preferred near pacemakers and neural structures'),
  bullet('Pacemaker interaction: Diathermy EMI may inhibit demand pacemakers → use bipolar, or if monopolar essential: place return plate to ensure current path does not cross the pacemaker; programme pacemaker to asynchronous (DOO/VOO) mode; have external pacemaker/defibrillator available'),
  heading3('Earthed vs. Isolated Electrical Equipment Classes'),
  tableRow('Class I', 'Earthed (grounded) equipment — most hospital equipment; earth connection provides protection'),
  tableRow('Class II', 'Double-insulated equipment — no earth required; safety from double insulation'),
  tableRow('Class III', 'Extra-low voltage (< 25V AC) — inherently safe'),
  tableRow('Type B Applied Parts', 'General body-surface contact; tolerate 100 μA leakage (macroshock protection only)'),
  tableRow('Type BF Applied Parts', 'Floating (isolated) applied parts; tolerate 10 μA; for surface contact near heart'),
  tableRow('Type CF Applied Parts', 'Cardiac-floating applied parts (intracardiac catheters); tolerate only 10 μA — critical for electrically susceptible patients'),
  heading3('Prevention of Electrical Hazards in OT'),
  bullet('Regular equipment maintenance and PAT (Portable Appliance Testing)'),
  bullet('Use of GFCI/RCD (ground fault circuit interrupter / residual current device) in non-isolated supply areas'),
  bullet('Anti-static flooring and footwear in older OTs (now replaced by isolation systems)'),
  bullet('Avoid pooling of fluids under patient or near electrical equipment'),
  bullet('Proper placement of diathermy return plate: Maximum contact area, over well-vascularised muscle, away from metal implants, ECG electrodes, and bony prominences'),
  bullet('Distance between ECG electrodes and surgical site to reduce diathermy interference'),
  heading3('Defibrillator Safety'),
  bullet('Before discharging: Ensure no personnel in contact with patient or table; remove all wet draping from contact'),
  bullet('Implantable cardiac defibrillators (ICDs): Inhibit or programme off if external diathermy planned; defibrillator paddles at least 15 cm from ICD generator'),
  para('Reference: Miller\'s Anesthesia 10e, Chapter 31 (Electrical Safety); Barash Clinical Anesthesia 9e, Chapter 26 (Equipment); Morgan & Mikhail\'s 7e, Chapter 2 (The Operating Room Environment)'),
  pageBreak()
];

// =================== QUESTION 10 ===================
const q10 = [
  heading1('Q10. Postoperative Analgesia for Paediatric Patients — Lower Abdominal Surgery and Thoracotomy'),
  heading2('Principles of Paediatric Pain Management'),
  para('Children experience pain as acutely as adults; undertreated pain causes physiological and psychological harm including PTSD, chronic pain, cardiovascular stress, and delayed wound healing. Multimodal analgesia is the cornerstone — combining regional techniques, NSAIDs, paracetamol, and opioids to minimise opioid-related side effects (PONV, respiratory depression, pruritus).'),
  para('Key differences in paediatric pharmacology: Higher liver cytochrome P450 activity in children > 2 years (faster drug metabolism); immature renal function < 3 months; neonates have increased CSF/plasma opioid ratio → increased CNS sensitivity; respiratory monitoring essential with systemic opioids.'),
  heading2('A. Post-Operative Analgesia for Lower Abdominal Surgery'),
  para('Common procedures: Appendicectomy, inguinal hernia repair, orchidopexy, Ladd\'s procedure, colostomy, pyeloplasty, ureteric reimplantation.'),
  heading3('1. Caudal Epidural Block (Gold Standard for Subumbilical Surgery)'),
  para('The most common regional technique in paediatric practice for procedures below the umbilicus (T10 level or below).'),
  bullet('Anatomy: In children, the sacral hiatus is easily identifiable; dural sac ends at S3 (vs S1–S2 in adults) — safer for caudal needle placement'),
  bullet('Technique: Patient in lateral decubitus (Sim\'s position) or prone; landmark is sacral hiatus between sacral cornua; 22G short-bevel needle at 60° then flatten once through sacrococcygeal ligament (loss of resistance/pop); single-shot injection'),
  bullet('Local anaesthetic (LA): Bupivacaine 0.25% 1 mL/kg (max 25 mL) or ropivacaine 0.2% 1 mL/kg; levobupivacaine 0.25% 1 mL/kg'),
  bullet('Volume determines dermatomal spread: 0.5 mL/kg → sacral; 1 mL/kg → lumbar; 1.25 mL/kg → mid-thoracic'),
  bullet('Duration: 4–6 hours with plain LA; extended to 8–12 hours with additives'),
  bullet('Additives to prolong duration: Clonidine 1–2 μg/kg (doubles block duration, mild sedation); dexamethasone 0.1 mg/kg; preservative-free morphine 30–70 μg/kg (24-hour analgesia; requires 12-hour respiratory monitoring); dexmedetomidine 1 μg/kg'),
  bullet('Contraindications: Local infection, coagulopathy, spina bifida occulta at sacrum, raised ICP (absolute)'),
  heading3('2. Ilioinguinal / Iliohypogastric Nerve Block'),
  bullet('For inguinal hernia repair, orchidopexy — blocks the L1 nerve roots supplying the inguinal region'),
  bullet('USG-guided: High-frequency probe; nerve between internal and external oblique muscles at anterior superior iliac spine (ASIS); inject 0.1–0.2 mL/kg 0.25% bupivacaine per side'),
  bullet('Alternative to caudal for unilateral groin procedures'),
  heading3('3. Transversus Abdominis Plane (TAP) Block'),
  bullet('Targets T6–L1 anterior abdominal wall nerves (within the fascial plane between internal oblique and transversus abdominis)'),
  bullet('USG-guided subcostal or lateral TAP; 0.2–0.3 mL/kg per side (e.g., ropivacaine 0.2% or bupivacaine 0.25%)'),
  bullet('Useful for laparoscopic surgery, appendicectomy, lower abdominal surgery'),
  heading3('4. Systemic Multimodal Analgesia'),
  bullet('Paracetamol (acetaminophen): IV/oral; 15 mg/kg/dose 6-hourly (max 60 mg/kg/day; reduce to 45 mg/kg/day in neonates); first-line non-opioid; safe in all ages'),
  bullet('NSAIDs — Ibuprofen: 5–10 mg/kg/dose 6–8 hourly (children > 3 months); adjunct to regional/paracetamol; reduces opioid requirement 30–40%; avoid in bleeding, renal impairment, reactive airways'),
  bullet('Diclofenac PR: 1 mg/kg/dose; useful post-operatively when IV access removed'),
  bullet('Ketorolac IV: 0.5 mg/kg (max 30 mg) for more potent NSAID effect; limit to 5 days'),
  bullet('Morphine IV PCA/NCA: 0.05–0.1 mg/kg bolus every 4 hours nurse-controlled for post-appendicectomy when regional insufficient; background infusion 10–20 μg/kg/hr only under close monitoring'),
  bullet('Tramadol: 1–2 mg/kg/dose 4–6 hourly; mild opioid + SNRI mechanism; avoid in children < 12 years with OSA or rapid metabolisers (CYP2D6) — FDA/EMA warnings'),
  heading2('B. Post-Operative Analgesia for Thoracotomy (Paediatric)'),
  para('Thoracotomy causes severe post-operative pain — one of the most painful surgical incisions. Inadequate analgesia → splinting → reduced respiratory effort → atelectasis, pneumonia, hypoventilation. Regional techniques are paramount.'),
  heading3('1. Thoracic Epidural Analgesia (TEA) — Gold Standard for Thoracotomy'),
  bullet('Provides superior analgesia and preserves respiratory function better than systemic opioids alone'),
  bullet('Placement: Thoracic epidural catheter at T4–T8 level (level of incision); under GA in children; loss of resistance to saline or air; tunnelled and secured'),
  bullet('Infusion: Bupivacaine 0.1% + fentanyl 2 μg/mL or morphine 10 μg/mL; infusion rate 0.1–0.3 mL/kg/hr (max 0.4 mL/kg/hr); PCEA from age 5–6 years'),
  bullet('Duration: Catheter maintained 48–72 hours post-thoracotomy'),
  bullet('Benefits: Reduced pulmonary complications, earlier extubation, reduced ICU stay, reduced opioid requirements, anti-inflammatory via sympathetic blockade'),
  bullet('Monitoring: Sensory level check, lower limb motor function, haemodynamic stability, sedation score, respiratory rate'),
  heading3('2. Paravertebral Block (PVB)'),
  bullet('Single injection or catheter technique; excellent alternative to TEA for unilateral thoracotomy'),
  bullet('Less sympathetic blockade than epidural → less hypotension'),
  bullet('USG-guided or anatomical landmark approach at thoracic paravertebral space; 0.5 mL/kg per level (e.g., ropivacaine 0.2–0.375%); or catheter 0.1–0.2 mL/kg/hr infusion'),
  bullet('Comparable analgesia to TEA for unilateral procedures; preferred if bilateral thoracotomy unfeasible with TEA or coagulopathy concern'),
  heading3('3. Intercostal Nerve Blocks'),
  bullet('Intraoperative surgeon-placed intercostal blocks at 2 levels above and below the incision; bupivacaine 0.25% 0.5 mL/kg total'),
  bullet('Duration: 6–8 hours only; may be combined with infusion catheter for prolonged effect'),
  bullet('Simple to perform; risk of pneumothorax (< 1%)'),
  heading3('4. Serratus Anterior Plane Block (SAP)'),
  bullet('Newer technique; blocks long thoracic nerve + lateral cutaneous branches of thoracic intercostals; covers T2–T9'),
  bullet('USG-guided; inject between serratus anterior and latissimus dorsi (superficial) or serratus anterior and intercostals (deep plane)'),
  bullet('Good for lateral thoracotomy, VATS, rib fractures; catheter-based for continuous infusion'),
  heading3('5. Systemic Multimodal Analgesia for Thoracotomy'),
  bullet('Paracetamol IV regular: 15 mg/kg 6-hourly; essential baseline'),
  bullet('Ketorolac/Ibuprofen IV: As above; reduces epidural local anaesthetic requirements'),
  bullet('IV Morphine PCA/NCA: 20–40 μg/kg/hr background + 10–20 μg/kg boluses (for children ≥ 5 years on PCA); nurse-controlled analgesia (NCA) for younger children'),
  bullet('Ketamine sub-anaesthetic: 0.1–0.2 mg/kg/hr IV infusion; reduces opioid requirements via NMDA antagonism; reduces central sensitisation'),
  bullet('Dexamethasone 0.15 mg/kg: Reduces inflammation, PONV, and adjuvant analgesic benefit'),
  bullet('Clonidine 1–2 μg/kg IV: α2-agonist; reduces opioid requirements, provides sedation and analgesia; avoid in haemodynamically unstable'),
  heading3('Post-Thoracotomy Pain Syndrome (Chronic Pain Prevention)'),
  bullet('Aggressive acute pain management reduces incidence of chronic post-thoracotomy pain (CPP)'),
  bullet('Ketamine and regional techniques reduce central sensitisation → lower CPP rates'),
  bullet('Gabapentin: Some evidence in adults; paediatric data limited; used in older children > 10 years for neuropathic component'),
  heading3('Monitoring and Safety'),
  bullet('All patients receiving regional analgesia or opioids: SpO₂ continuous, respiratory rate, pain score (FLACC for < 4 years; NRS for > 7 years; FACES scale 4–7 years), sedation score'),
  bullet('Epidural: Hourly sensory level + lower limb motor check, BP every 4 hours, infusion pump double-check'),
  bullet('Local anaesthetic toxicity: Calculate maximum dose carefully; signs of LAST → Intralipid 20% rescue (1.5 mL/kg IV bolus)'),
  para('Reference: Miller\'s Anesthesia 10e, Chapter 93 (Paediatric Anaesthesia); Morgan & Mikhail\'s 7e, Chapter 42; Barash Clinical Anesthesia 9e, Chapter 54 (Paediatric Anaesthesia); Smith\'s Anesthesia for Infants and Children 9e, Chapter 15 (Pain Management)')
];

// BUILD DOCUMENT
const doc = new Document({
  title: 'Anaesthesia Examination Answers',
  description: '10 Model Answers based on Standard Anaesthesia Textbooks',
  styles: {
    default: {
      document: {
        run: { font: 'Calibri', size: 24, color: '000000' }
      },
      heading1: {
        run: { font: 'Calibri', bold: true, size: 32, color: '1F3864' },
        paragraph: { spacing: { before: 480, after: 240 } }
      },
      heading2: {
        run: { font: 'Calibri', bold: true, size: 28, color: '2E75B6' },
        paragraph: { spacing: { before: 320, after: 160 } }
      },
      heading3: {
        run: { font: 'Calibri', bold: true, size: 26, color: '2E75B6' },
        paragraph: { spacing: { before: 240, after: 120 } }
      }
    }
  },
  sections: [{
    properties: {
      page: {
        margin: { top: 720, right: 720, bottom: 720, left: 900 }
      }
    },
    children: [
      ...titlePage,
      ...q1, ...q2, ...q3, ...q4, ...q5,
      ...q6, ...q7, ...q8, ...q9, ...q10
    ]
  }]
});

Packer.toBuffer(doc).then(buffer => {
  fs.writeFileSync('/home/daytona/workspace/anaesthesia-exam/Anaesthesia_Exam_Answers.docx', buffer);
  console.log('SUCCESS: Document created');
}).catch(err => {
  console.error('ERROR:', err.message);
  process.exit(1);
});

cd /home/daytona/workspace/anaesthesia-exam && node build_doc.js 2>&1