const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Hypovolemic Shock in GI Bleeding";
pres.author = "Emergency Medicine";

// ─── Color Palette ───────────────────────────────────────────────────────────
const C = {
  bg:       "0D1B2A",   // deep navy (dominant)
  bgLight:  "112233",   // slide body bg
  accent1:  "E63946",   // vivid red (blood / danger)
  accent2:  "F4A261",   // amber (warning)
  accent3:  "2EC4B6",   // teal (labs / treatment)
  white:    "FFFFFF",
  offWhite: "D6E4F0",
  yellow:   "FFD166",
  gray:     "8BA3BC",
  darkBg:   "071525",
};

// ─── Helper: add slide background rect ───────────────────────────────────────
function bgRect(slide, color) {
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    x: 0, y: 0, w: "100%", h: "100%",
    fill: { color: color || C.bg },
    line: { color: color || C.bg },
  });
}

// ─── Helper: section header bar ──────────────────────────────────────────────
function headerBar(slide, title, color) {
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    x: 0, y: 0, w: "100%", h: 1.0,
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    x: 0.3, y: 0.1, w: 9.4, h: 0.75,
    fontSize: 28, bold: true, color: C.white,
    fontFace: "Calibri", align: "left", valign: "middle", margin: 0,
  });
}

// ─── Helper: colored left stripe ─────────────────────────────────────────────
function leftStripe(slide, color) {
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    x: 0, y: 0, w: 0.15, h: "100%",
    fill: { color: color || C.accent1 },
    line: { color: color || C.accent1 },
  });
}

// ─── Helper: bullet list ─────────────────────────────────────────────────────
function bullets(items, opts = {}) {
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    options: {
      bullet: { code: "2022" },
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      fontSize: opts.fontSize || 15,
      bold: opts.bold || false,
      breakLine: i < items.length - 1,
      paraSpaceBefore: opts.spaceBefore || 4,
    },
  }));
}

// ─── Helper: numbered list ────────────────────────────────────────────────────
function numbered(items, opts = {}) {
  return items.map((t, i) => ({
    text: t,
    options: {
      bullet: { type: "number" },
      color: opts.color || C.offWhite,
      fontSize: opts.fontSize || 15,
      bold: opts.bold || false,
      breakLine: i < items.length - 1,
      paraSpaceBefore: opts.spaceBefore || 4,
    },
  }));
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 1 — TITLE
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  // Deep background
  bgRect(s, C.darkBg);

  // Red diagonal accent band
  s.addShape(pres.ShapeType.rect, {
    x: 0, y: 3.6, w: "100%", h: 0.12,
    fill: { color: C.accent1 }, line: { color: C.accent1 },
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  // Large red block left
  s.addShape(pres.ShapeType.rect, {
    x: 0, y: 0, w: 0.55, h: "100%",
    fill: { color: C.accent1 }, line: { color: C.accent1 },
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  s.addText("HYPOVOLEMIC SHOCK", {
    x: 0.8, y: 0.55, w: 9, h: 1.2,
    fontSize: 42, bold: true, color: C.white,
    fontFace: "Calibri", align: "left", charSpacing: 3,
  });
  s.addText("IN GASTROINTESTINAL BLEEDING", {
    x: 0.8, y: 1.65, w: 9, h: 0.8,
    fontSize: 26, bold: false, color: C.accent2,
    fontFace: "Calibri", align: "left",
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  s.addText("Emergency Medicine — Pathophysiology, Diagnosis & Step-by-Step Management", {
    x: 0.8, y: 2.5, w: 9, h: 0.55,
    fontSize: 14, color: C.gray, fontFace: "Calibri", align: "left",
  });

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    x: 0, y: 5.2, w: "100%", h: 0.425,
    fill: { color: "0A1520" }, line: { color: "0A1520" },
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  s.addText("Tintinalli's Emergency Medicine  ·  Rosen's Emergency Medicine  ·  Guyton & Hall Physiology  ·  Sabiston Surgery", {
    x: 0.6, y: 5.22, w: 9, h: 0.38,
    fontSize: 9, color: C.gray, fontFace: "Calibri", align: "left",
  });
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 2 — OVERVIEW / AGENDA
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bgRect(s);
  headerBar(s, "Outline", C.accent1);

  const topics = [
    "Definition & Classification of Shock",
    "Causes of GI Bleeding (Upper & Lower)",
    "Pathophysiology — Detailed Cascade",
    "Compensatory Mechanisms",
    "ATLS Classification of Hemorrhagic Shock",
    "Signs & Symptoms",
    "Diagnosis — Labs, Imaging & Risk Scores",
    "Step-by-Step Emergency Management",
    "Resuscitation Strategies & Massive Transfusion",
    "Endoscopy, Interventional Radiology & Surgery",
    "Disposition & Monitoring",
  ];

  s.addText(numbered(topics, { fontSize: 15, spaceBefore: 6 }), {
    x: 0.5, y: 1.1, w: 9, h: 4.3,
    fontFace: "Calibri", valign: "top",
  });
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 3 — DEFINITION & CLASSIFICATION
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bgRect(s);
  leftStripe(s, C.accent1);
  headerBar(s, "Definition & Classification of Shock", C.accent1);

  s.addText("SHOCK DEFINED", {
    x: 0.35, y: 1.1, w: 9, h: 0.4,
    fontSize: 13, bold: true, color: C.accent2,
    fontFace: "Calibri", charSpacing: 2,
  });
  s.addText(
    "Shock is a state of inadequate tissue perfusion resulting in cellular hypoxia and organ dysfunction.\n" +
    "Defined as systolic BP <90 mmHg or MAP <65 mmHg with evidence of end-organ dysfunction.",
    {
      x: 0.35, y: 1.45, w: 9.2, h: 0.75,
      fontSize: 13.5, color: C.offWhite, fontFace: "Calibri", wrap: true,
    }
  );

  // 4 boxes
  const types = [
    { label: "HYPOVOLEMIC", desc: "↓ intravascular volume\n(hemorrhage, GI loss)", color: C.accent1 },
    { label: "DISTRIBUTIVE", desc: "Septic, anaphylactic,\nneurogenic", color: "7B2D8B" },
    { label: "CARDIOGENIC", desc: "Pump failure\n(MI, cardiomyopathy)", color: "1E6091" },
    { label: "OBSTRUCTIVE", desc: "PE, tamponade,\ntension pneumothorax", color: "1A7A4A" },
  ];

  types.forEach((t, i) => {
    const x = 0.25 + i * 2.4;
    s.addShape(pres.ShapeType.roundRect, {
      x, y: 2.35, w: 2.2, h: 1.35,
      rectRadius: 0.08,
      fill: { color: t.color },
      line: { color: C.white, width: 1 },
    });
    s.addText(t.label, {
      x, y: 2.38, w: 2.2, h: 0.42,
      fontSize: 12, bold: true, color: C.white,
      fontFace: "Calibri", align: "center", valign: "middle", margin: 0,
    });
    s.addText(t.desc, {
      x, y: 2.78, w: 2.2, h: 0.88,
      fontSize: 11, color: C.white,
      fontFace: "Calibri", align: "center", valign: "top",
    });
  });

  s.addText("★ GI BLEEDING IS A PRIMARY CAUSE OF HYPOVOLEMIC SHOCK IN THE ED", {
    x: 0.25, y: 3.85, w: 9.5, h: 0.42,
    fontSize: 13, bold: true, color: C.yellow,
    fontFace: "Calibri", align: "center",
    fill: { color: "1A0A00" },
  });

  s.addText(
    "Key hemodynamic hallmarks of hypovolemic shock: ↓ CO · ↑ SVR · ↓ ScvO₂ · ↑ HR · ↓ Pulse pressure\n" +
    "GI bleeding accounts for ~300,000 hospitalizations/year in the US — upper GI 70%, lower GI 30%",
    {
      x: 0.35, y: 4.3, w: 9.2, h: 0.9,
      fontSize: 12, color: C.gray, fontFace: "Calibri", wrap: true,
    }
  );
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 4 — CAUSES OF GI BLEEDING
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bgRect(s);
  leftStripe(s, C.accent2);
  headerBar(s, "Causes of GI Bleeding", C.accent2);

  // Upper GI
  s.addShape(pres.ShapeType.rect, {
    x: 0.3, y: 1.1, w: 4.3, h: 0.38,
    fill: { color: C.accent1 }, line: { color: C.accent1 },
  });
  s.addText("UPPER GI BLEEDING  (proximal to Ligament of Treitz)", {
    x: 0.3, y: 1.1, w: 4.3, h: 0.38,
    fontSize: 12, bold: true, color: C.white, fontFace: "Calibri",
    align: "center", valign: "middle", margin: 0,
  });
  s.addText(bullets([
    "Peptic ulcer disease — Most common (45–60%)",
    "Esophageal / gastric varices — (cirrhosis, portal HTN)",
    "Mallory-Weiss tear — Forceful vomiting",
    "Esophagitis / gastritis / duodenitis",
    "Dieulafoy's lesion — Aberrant submucosal artery",
    "Gastric antral vascular ectasia (GAVE)",
    "Aortoenteric fistula — Post-aortic graft",
    "Malignancy (gastric / esophageal cancer)",
  ], { fontSize: 13 }), {
    x: 0.3, y: 1.5, w: 4.3, h: 3.7,
    fontFace: "Calibri", valign: "top",
  });

  // Lower GI
  s.addShape(pres.ShapeType.rect, {
    x: 5.0, y: 1.1, w: 4.6, h: 0.38,
    fill: { color: "1A6091" }, line: { color: "1A6091" },
  });
  s.addText("LOWER GI BLEEDING  (distal to Ligament of Treitz)", {
    x: 5.0, y: 1.1, w: 4.6, h: 0.38,
    fontSize: 12, bold: true, color: C.white, fontFace: "Calibri",
    align: "center", valign: "middle", margin: 0,
  });
  s.addText(bullets([
    "Diverticulosis — Most common LGIB (40%+)",
    "Ischemic colitis — Especially in elderly",
    "Angiodysplasia / AVM",
    "Colorectal cancer / polyps",
    "Inflammatory bowel disease (Crohn's, UC)",
    "Anorectal disease — Hemorrhoids, fissures",
    "Meckel's diverticulum — Young patients",
    "Infectious colitis — Campylobacter, C. diff",
  ], { fontSize: 13 }), {
    x: 5.0, y: 1.5, w: 4.6, h: 3.7,
    fontFace: "Calibri", valign: "top",
  });

  // Key note
  s.addText("⚠  One-third of presumed LGIB has an upper GI source — always assess with NG tube or upper endoscopy first", {
    x: 0.3, y: 5.2, w: 9.4, h: 0.32,
    fontSize: 11, color: C.yellow, fontFace: "Calibri", align: "center",
  });
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 5 — PATHOPHYSIOLOGY OVERVIEW
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bgRect(s);
  leftStripe(s, C.accent1);
  headerBar(s, "Pathophysiology — The Hemorrhagic Cascade", C.accent1);

  // Cascade flow chart using boxes + arrows
  const steps = [
    { text: "GI HEMORRHAGE\n(Acute Blood Loss)", color: C.accent1 },
    { text: "↓ Circulating Blood Volume\n(Intravascular Depletion)", color: "7B1E1E" },
    { text: "↓ Venous Return (Preload)\n↓ Right Atrial Pressure", color: "8B2500" },
    { text: "↓ Cardiac Output\n(Frank-Starling mechanism)", color: "1A4A6E" },
    { text: "↓ Mean Arterial Pressure\n↓ Oxygen Delivery to Tissues", color: "0D3A50" },
    { text: "CELLULAR HYPOXIA\n→ Anaerobic Metabolism → Lactic Acidosis", color: "1A2A10" },
  ];

  const boxW = 1.45, boxH = 0.72, startX = 0.22, gapX = 0.14, y = 1.15;
  steps.forEach((st, i) => {
    const x = startX + i * (boxW + gapX);
    s.addShape(pres.ShapeType.roundRect, {
      x, y, w: boxW, h: boxH,
      rectRadius: 0.07,
      fill: { color: st.color },
      line: { color: C.white, width: 1 },
    });
    s.addText(st.text, {
      x, y, w: boxW, h: boxH,
      fontSize: 9.5, color: C.white, bold: true,
      fontFace: "Calibri", align: "center", valign: "middle",
    });
    if (i < steps.length - 1) {
      s.addShape(pres.ShapeType.rect, {
        x: x + boxW, y: y + boxH / 2 - 0.04, w: gapX, h: 0.08,
        fill: { color: C.accent2 }, line: { color: C.accent2 },
      });
    }
  });

  // Sympathetic activation box
  s.addShape(pres.ShapeType.rect, {
    x: 0.22, y: 2.0, w: "95%", h: 0.05,
    fill: { color: C.accent2 }, line: { color: C.accent2 },
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    x: 0.22, y: 2.1, w: 9.5, h: 0.3,
    fontSize: 13, bold: true, color: C.accent2,
    fontFace: "Calibri", align: "center",
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      title: "Cardiovascular",
      items: ["↑ Heart rate (tachycardia)", "↑ Myocardial contractility", "Arteriolar constriction → ↑ SVR", "Venous constriction → ↑ venous return", "Redistribution to heart & brain"],
    },
    {
      title: "Hormonal (RAAS + ADH)",
      items: ["↑ Renin → Angiotensin II", "↑ Aldosterone → Na⁺ / H₂O retention", "↑ ADH / Vasopressin → ↑ water reabsorption", "↑ Cortisol & catecholamines", "Stress hyperglycemia"],
    },
    {
      title: "Cellular / Microvascular",
      items: ["Transcapillary fluid shift (Starling)", "↓ Capillary hydrostatic pressure", "Protein oncotic absorption from interstitium", "Microcirculatory failure in Class III–IV", "Reperfusion injury & SIRS if prolonged"],
    },
  ];

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    s.addShape(pres.ShapeType.roundRect, {
      x, y: 2.5, w: 3.1, h: 2.9,
      rectRadius: 0.08,
      fill: { color: "0C1E30" },
      line: { color: C.accent3, width: 1.5 },
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      x, y: 2.5, w: 3.1, h: 0.38,
      fontSize: 12, bold: true, color: C.accent3,
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      x: x + 0.1, y: 2.9, w: 2.9, h: 2.45,
      fontFace: "Calibri", valign: "top",
    });
  });
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 6 — DETAILED PHYSIOLOGY
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bgRect(s);
  leftStripe(s, C.accent3);
  headerBar(s, "Compensatory Physiology in Detail", C.accent3);

  const leftItems = [
    "Baroreceptors in carotid sinus & aortic arch detect ↓ BP",
    "Signal to vasomotor center → massive sympathetic discharge",
    "HR increases from 72 to 160–180 bpm",
    "Arterioles constrict → ↑ total peripheral resistance (TPR)",
    "Venous reservoirs constrict → maintain venous return",
    "CNS ischemic response: 'last stand' reflex — extreme SNS stimulation when brain O₂ falls, maintains BP at second plateau ~50 mmHg",
    "Coronary & cerebral blood flow preferentially preserved",
  ];

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    "10% blood loss: no measurable change in BP or HR",
    "15–20% loss: tachycardia + narrowed pulse pressure begins",
    "30–40% loss: hypotension occurs (BP maintained by reflexes until this point)",
    "40–45% loss: cardiac output and BP fall to zero",
    "Without sympathetic reflexes: only 15–20% loss = death",
    "With intact reflexes: can survive 30–40% loss",
    "Pa = CO × TPR: pressure maintained by ↑ TPR even as CO falls",
  ];

  s.addText("Sympathetic Reflex Compensations", {
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    fontSize: 13, bold: true, color: C.accent2,
    fontFace: "Calibri",
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    x: 0.35, y: 1.45, w: 4.5, h: 3.9,
    fontFace: "Calibri", valign: "top",
  });

  s.addShape(pres.ShapeType.line, {
    x: 5.1, y: 1.1, w: 0, h: 4.35,
    line: { color: C.gray, width: 0.5 },
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  s.addText("Blood Volume Threshold Effects", {
    x: 5.2, y: 1.1, w: 4.5, h: 0.35,
    fontSize: 13, bold: true, color: C.accent2,
    fontFace: "Calibri",
  });
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    x: 5.2, y: 1.45, w: 4.5, h: 3.9,
    fontFace: "Calibri", valign: "top",
  });

  // Bottom note
  s.addShape(pres.ShapeType.rect, {
    x: 0.22, y: 5.25, w: 9.56, h: 0.27,
    fill: { color: "0C1E30" }, line: { color: "0C1E30" },
  });
  s.addText("Source: Guyton & Hall Medical Physiology — Blood volume estimated at 7% of ideal body weight (~4,900 mL in 70 kg adult)", {
    x: 0.22, y: 5.25, w: 9.56, h: 0.27,
    fontSize: 9, color: C.gray, fontFace: "Calibri", align: "center",
  });
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 7 — ATLS CLASSIFICATION
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bgRect(s);
  headerBar(s, "ATLS Classification of Hemorrhagic Shock", C.accent1);

  const headers = ["Parameter", "Class I", "Class II", "Class III", "Class IV"];
  const rows = [
    ["Blood Loss (mL)", "<750", "800–1,500", "1,500–2,000", ">2,000"],
    ["Blood Loss (%)", "<15%", "15–30%", "30–40%", ">40%"],
    ["Heart Rate (bpm)", "<100", "100–120", "120–140", ">140"],
    ["Systolic BP", "Normal", "Normal", "↓", "↓↓"],
    ["Pulse Pressure", "Normal/↑", "↓", "↓", "↓↓"],
    ["Respiratory Rate", "14–20", "20–30", "30–40", ">35"],
    ["Urine Output (mL/hr)", ">30", "20–30", "5–15", "Negligible"],
    ["Mental Status", "Slightly anxious", "Mildly anxious", "Confused / aggressive", "Lethargic / coma"],
    ["Capillary Refill", "Normal", "Delayed", "Delayed", "Absent"],
    ["Fluid Replacement", "Crystalloid ± blood", "Crystalloid", "Blood + crystalloid", "Blood + surgery/IR"],
  ];

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  // Header row
  headers.forEach((h, col) => {
    const x = 0.12 + col * 1.93;
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      x, y: 1.0, w: 1.88, h: 0.38,
      fill: { color: classColors[col] || "1A0000" },
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      x, y: 1.0, w: 1.88, h: 0.38,
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  s.addText("Source: ATLS (American College of Surgeons) · Mulholland & Greenfield Surgery", {
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    fontSize: 8, color: C.gray, fontFace: "Calibri", align: "center",
  });
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 8 — SIGNS & SYMPTOMS
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bgRect(s);
  leftStripe(s, C.accent2);
  headerBar(s, "Signs & Symptoms", C.accent2);

  const cols = [
    {
      title: "🩸 GI Bleeding Signs",
      color: C.accent1,
      items: [
        "Hematemesis — Fresh blood or 'coffee-ground' vomitus",
        "Melena — Black, tarry, malodorous stools (upper source)",
        "Hematochezia — Bright red blood per rectum (rapid UGIB or LGIB)",
        "Occult blood — Guaiac-positive stool, iron-deficiency anemia",
        "Rectal bleeding — Variable from hemorrhoids to massive LGIB",
      ],
    },
    {
      title: "💉 Shock Signs",
      color: "1A6091",
      items: [
        "Tachycardia — Often earliest sign (HR >100 bpm)",
        "Hypotension — Systolic <90 mmHg (late sign!)",
        "Narrow pulse pressure (<20 mmHg)",
        "Tachypnea — Compensatory hyperventilation",
        "Pallor, diaphoresis, cold clammy skin",
        "Delayed capillary refill (>2 sec)",
        "Oliguria or anuria (<0.5 mL/kg/hr)",
        "Altered mental status — Confusion, agitation, obtundation",
      ],
    },
    {
      title: "🔍 History Clues",
      color: "1A5200",
      items: [
        "NSAIDs / aspirin / anticoagulant use",
        "Alcohol use / liver disease / cirrhosis",
        "Prior peptic ulcer disease or varices",
        "H. pylori history",
        "Prior GI surgeries / aortic graft",
        "Syncope / presyncope / lightheadedness",
        "Orthostatic symptoms",
        "Weight loss → malignancy?",
      ],
    },
  ];

  cols.forEach((col, i) => {
    const x = 0.22 + i * 3.28;
    s.addShape(pres.ShapeType.roundRect, {
      x, y: 1.1, w: 3.1, h: 0.38,
      rectRadius: 0.06,
      fill: { color: col.color },
      line: { color: col.color },
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    s.addText(col.title, {
      x, y: 1.1, w: 3.1, h: 0.38,
      fontSize: 12, bold: true, color: C.white,
      fontFace: "Calibri", align: "center", valign: "middle", margin: 0,
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      x: x + 0.05, y: 1.5, w: 3.05, h: 3.9,
      fontFace: "Calibri", valign: "top",
    });
  });

  s.addText("⚠ Tachycardia may be masked by beta-blockers, pacemakers, or athletic conditioning — do not rely on HR alone!", {
    x: 0.22, y: 5.2, w: 9.56, h: 0.3,
    fontSize: 11, color: C.yellow, fontFace: "Calibri", align: "center",
    bold: true,
  });
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 9 — DIAGNOSIS
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bgRect(s);
  leftStripe(s, C.accent3);
  headerBar(s, "Diagnosis — Labs, Imaging & Risk Stratification", C.accent3);

  // Labs column
  s.addText("LABORATORY TESTS", {
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  s.addText(bullets([
    "CBC — Hgb, Hct (may be normal early in acute bleeding)",
    "BMP / Chem — BUN:Creatinine ratio >30 suggests upper GI source",
    "Coagulation — PT, INR, aPTT, fibrinogen",
    "Type & Screen / Crossmatch — Order IMMEDIATELY",
    "Lactate — Elevated in tissue hypoperfusion (>2 mmol/L)",
    "ABG — pH, base excess, PaO₂, CO₂",
    "LFTs, albumin — Assess liver disease / varices risk",
    "Platelet count — Thrombocytopenia common in cirrhosis",
    "TEG / ROTEM — Viscoelastic testing for massive hemorrhage",
    "Shock Index = HR ÷ SBP (>1.0 = severe shock)",
  ], { fontSize: 12, spaceBefore: 3 }), {
    x: 0.3, y: 1.42, w: 4.5, h: 4.0,
    fontFace: "Calibri", valign: "top",
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  // Right column
  s.addText("IMAGING & ENDOSCOPY", {
    x: 5.1, y: 1.1, w: 4.7, h: 0.3,
    fontSize: 12, bold: true, color: C.accent2, fontFace: "Calibri", charSpacing: 1,
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  s.addText(bullets([
    "POCUS — IVC collapsibility, 'kissing walls' LV sign, pericardial effusion",
    "Chest/Abdominal X-ray — Free air, obstruction, aortic widening",
    "CT Angiography — Localizes bleeding (≥0.3–0.5 mL/min), preferred before IR",
    "Upper GI Endoscopy — Gold standard for upper GI; both diagnostic & therapeutic",
    "Colonoscopy — Locates lower GI source after prep (if stable)",
    "Tagged RBC scan (Tc-99m) — Detects slow bleeding ≥0.1 mL/min",
    "Angiography — Detects ≥0.5 mL/min; allows embolization",
  ], { fontSize: 12, spaceBefore: 3 }), {
    x: 5.1, y: 1.42, w: 4.6, h: 2.4,
    fontFace: "Calibri", valign: "top",
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  s.addText("RISK SCORES", {
    x: 5.1, y: 3.95, w: 4.7, h: 0.3,
    fontSize: 12, bold: true, color: C.accent2, fontFace: "Calibri", charSpacing: 1,
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  const scores = [
    ["Glasgow-Blatchford (GBS)", "Pre-endoscopy; predicts need for intervention (score ≥7 = high risk)"],
    ["Rockall Score", "Post-endoscopy; predicts rebleeding & mortality"],
    ["AIMS65", "Albumin, INR, Mental status, SBP, Age ≥65; predicts mortality"],
    ["Shock Index (SI)", "HR/SBP — SI >1.0 predicts hemodynamic instability"],
  ];
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    s.addText([
      { text: sc[0] + ": ", options: { bold: true, color: C.yellow, fontSize: 11 } },
      { text: sc[1], options: { color: C.offWhite, fontSize: 11 } },
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      x: 5.1, y: 4.27 + i * 0.29, w: 4.6, h: 0.28,
      fontFace: "Calibri",
    });
  });
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 10 — STEP-BY-STEP EMERGENCY MANAGEMENT
// ──────────────────────────────────────────────────────────────────────────────
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  const s = pres.addSlide();
  bgRect(s);
  headerBar(s, "Step-by-Step Emergency Management", C.accent1);

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    {
      num: "1",
      title: "IMMEDIATE RESUSCITATION (0–5 min)",
      color: C.accent1,
      items: [
        "Activate massive transfusion protocol (MTP) if severe shock",
        "Two large-bore IVs (16G or larger) in antecubital fossa",
        "Intraosseous access if IV fails",
        "Supplemental O₂ / prepare for airway management",
        "Cardiac monitor, pulse oximetry, continuous BP monitoring",
        "Position: supine, legs elevated (Trendelenburg if BP <70)",
      ],
    },
    {
      num: "2",
      title: "FLUID RESUSCITATION (5–20 min)",
      color: C.accent2,
      items: [
        "Warm isotonic crystalloid (NS or LR) — 1–2 L bolus initially",
        "Goal MAP ≥65 mmHg (permissive hypotension ~80–90 SBP until bleeding controlled)",
        "Type & Screen STAT — prepare blood products",
        "pRBCs 1 unit if Hgb <7 g/dL or hemodynamically unstable",
        "For hemorrhagic shock: 1:1:1 ratio pRBC : FFP : Platelets (MTP)",
        "Target: Hgb 7–9, PLT >50k, INR <1.5, fibrinogen >200",
      ],
    },
    {
      num: "3",
      title: "DIAGNOSTIC WORKUP (Simultaneous)",
      color: C.accent3,
      items: [
        "CBC, BMP, coags, type & cross, lactate, LFTs, ABG",
        "POCUS — assess cardiac function, IVC collapsibility",
        "NG tube lavage — bloody = upper GI source",
        "Risk stratify: GBS, Rockall, AIMS65",
        "CT angiography if hemodynamically stable",
      ],
    },
  ];

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    // Title
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  s.addText("Simultaneously stabilize + diagnose + call GI / Surgery / IR team early", {
    x: 0.18, y: 5.25, w: 9.6, h: 0.3,
    fontSize: 11.5, bold: true, color: C.yellow, fontFace: "Calibri", align: "center",
  });
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 11 — RESUSCITATION STRATEGIES
// ──────────────────────────────────────────────────────────────────────────────
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  const s = pres.addSlide();
  bgRect(s);
  leftStripe(s, C.accent1);
  headerBar(s, "Resuscitation Strategies & Massive Transfusion Protocol", C.accent1);

  // MTP Box
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    x: 0.3, y: 1.1, w: 4.5, h: 4.2,
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  s.addText("MASSIVE TRANSFUSION PROTOCOL (MTP)", {
    x: 0.3, y: 1.1, w: 4.5, h: 0.42,
    fontSize: 12, bold: true, color: C.accent1,
    fontFace: "Calibri", align: "center", valign: "middle",
  });
  s.addText(bullets([
    "Trigger: >10 units pRBC in 24h, or >4 units in 1h, or ongoing hemorrhagic shock",
    "Ratio: 1:1:1 — pRBC : FFP : Platelets",
    "Alternative: Fresh Whole Blood (superior if available)",
    "Add cryoprecipitate if fibrinogen <150–200 mg/dL",
    "Tranexamic Acid (TXA): 1g IV over 10 min (within 3h of bleeding onset)",
    "Calcium gluconate — Replace after every 4 units pRBC to prevent hypocalcemia",
    "Warm all fluids — Target normothermia",
    "Monitor with TEG / ROTEM for goal-directed transfusion",
    "Avoid overresuscitation with crystalloids — dilutional coagulopathy risk",
  ], { fontSize: 11.5, spaceBefore: 4 }), {
    x: 0.4, y: 1.52, w: 4.3, h: 3.7,
    fontFace: "Calibri", valign: "top",
  });

  // Targets Box
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    x: 5.1, y: 1.1, w: 4.6, h: 2.1,
    rectRadius: 0.1,
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  s.addText("RESUSCITATION ENDPOINTS", {
    x: 5.1, y: 1.1, w: 4.6, h: 0.38,
    fontSize: 12, bold: true, color: C.accent3,
    fontFace: "Calibri", align: "center", valign: "middle",
  });
  const targets = [
    ["MAP", "≥65 mmHg (60 in traumatic hemorrhage)"],
    ["Hgb", "7–9 g/dL (restrictive strategy)"],
    ["Platelets", ">50,000/μL (>100k if intracranial)"],
    ["INR", "<1.5"],
    ["Fibrinogen", ">200 mg/dL"],
    ["Lactate", "Normalize (<2 mmol/L)"],
    ["Urine Output", "≥0.5 mL/kg/hr"],
    ["Temperature", ">35°C"],
  ];
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    s.addText([
      { text: t[0] + ": ", options: { bold: true, color: C.yellow, fontSize: 11.5 } },
      { text: t[1], options: { color: C.offWhite, fontSize: 11.5 } },
    ], {
      x: 5.2, y: 1.5 + i * 0.215, w: 4.4, h: 0.22,
      fontFace: "Calibri",
    });
  });

  // "Lethal Triad" box
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    x: 5.1, y: 3.3, w: 4.6, h: 1.95,
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  s.addText("☠ LETHAL TRIAD — Avoid / Reverse", {
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    fontSize: 12, bold: true, color: C.accent2,
    fontFace: "Calibri", align: "center", valign: "middle",
  });
  s.addText(bullets([
    "Hypothermia — Impairs clotting enzymes; warm fluids & blankets",
    "Acidosis — Metabolic (lactic); bicarbonate rarely needed, fix perfusion",
    "Coagulopathy — Dilutional + consumptive; FFP + cryo + TXA",
  ], { fontSize: 12, spaceBefore: 5 }), {
    x: 5.2, y: 3.7, w: 4.4, h: 1.5,
    fontFace: "Calibri", valign: "top",
  });
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 12 — HEMOSTASIS: ENDOSCOPY / IR / SURGERY
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bgRect(s);
  leftStripe(s, C.accent3);
  headerBar(s, "Hemostasis — Endoscopy, IR & Surgery", C.accent3);

  const cols = [
    {
      title: "ENDOSCOPIC THERAPY",
      color: C.accent3,
      items: [
        "Upper GI: EGD within 24h (12–24h if high risk, after stabilization)",
        "Injection therapy — Epinephrine 1:10,000 into bleeding vessel",
        "Thermal coagulation — Heater probe, bipolar cautery",
        "Hemoclips — Mechanical closure of bleeding vessel",
        "Band ligation — Esophageal varices (variceal bleeding)",
        "TIPS — Transjugular intrahepatic portosystemic shunt for refractory varices",
        "Colonoscopy — LGIB if hemodynamically stable post-prep",
        "Lower GI endoscopic coagulation / clips",
      ],
    },
    {
      title: "INTERVENTIONAL RADIOLOGY",
      color: C.accent2,
      items: [
        "CT angiography first to localize bleeding",
        "Mesenteric angiography — Active bleeding ≥0.5 mL/min",
        "Transcatheter arterial embolization (TAE) — Coils, gel foam",
        "Particularly useful for lower GI diverticular bleeding",
        "Bronchial artery embolization for hemoptysis",
        "TIPS for portal hypertension / variceal hemorrhage",
        "Superior to surgery in frail patients — less morbidity",
      ],
    },
    {
      title: "SURGERY",
      color: C.accent1,
      items: [
        "Indications: Failure of endoscopy + IR, perforation, peritonitis",
        "Massive hemorrhage requiring >6 units pRBC with no source control",
        "Upper GI: Oversew ulcer, vagotomy, antrectomy",
        "Variceal: Splenorenal shunt, devascularization procedures",
        "Lower GI: Segmental colectomy (must localize first!)",
        "Damage Control Surgery — Temporary packing + ICU stabilization",
        "Total colectomy as last resort for unlocalized LGIB",
      ],
    },
  ];

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      x, y: 1.08, w: 3.1, h: 0.38,
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      fontSize: 11.5, bold: true, color: C.white,
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  s.addText("Escalate to surgery early: anesthesia, OR, and blood bank should be notified when MTP is activated", {
    x: 0.22, y: 5.25, w: 9.56, h: 0.28,
    fontSize: 11, color: C.yellow, bold: true, fontFace: "Calibri", align: "center",
  });
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 13 — VARICEAL BLEEDING SPECIAL TOPIC
// ──────────────────────────────────────────────────────────────────────────────
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  const s = pres.addSlide();
  bgRect(s);
  leftStripe(s, "7B2D8B");
  headerBar(s, "Special Topic: Variceal Bleeding in Portal Hypertension", "7B2D8B");

  s.addText(
    "Variceal hemorrhage carries 20–30% mortality per episode. Cirrhosis → portal HTN → ↑ resistance → collateral formation (esophageal & gastric varices).",
    {
      x: 0.35, y: 1.12, w: 9.3, h: 0.55,
      fontSize: 13, color: C.offWhite, fontFace: "Calibri", wrap: true,
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    {
      title: "Initial Management",
      color: C.accent1,
      items: [
        "Airway protection — High aspiration risk; early intubation",
        "Avoid over-transfusion: target Hgb 7–8 (over-resuscitation worsens portal pressure)",
        "Terlipressin 2 mg IV q4h (or octreotide 50 mcg bolus + 50 mcg/h infusion)",
        "Vasoactive agent BEFORE endoscopy — Reduces mortality",
        "Prophylactic antibiotics: ceftriaxone 1g/day × 7 days (reduces SBP & rebleeding)",
        "Lactulose / rifaximin for hepatic encephalopathy prevention",
      ],
    },
    {
      title: "Endoscopic & Definitive",
      color: "7B2D8B",
      items: [
        "EGD within 12 hours of presentation",
        "Esophageal variceal ligation (EVL) — First-line over sclerotherapy",
        "N-butyl-2-cyanoacrylate (glue) for gastric varices",
        "Balloon tamponade (Sengstaken-Blakemore tube) — Bridge to definitive therapy, max 24h",
        "TIPS — If endoscopy fails; 90% success in hemorrhage control",
        "Early TIPS (within 72h) in Child-Pugh B/C — Improves survival",
        "Beta-blockers (propranolol/nadolol) + EVL for secondary prophylaxis",
      ],
    },
  ];

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      x, y: 1.75, w: 4.6, h: 0.38,
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      fontSize: 12, bold: true, color: C.white,
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  });

  s.addText("MELD score predicts 90-day mortality in cirrhotic patients with variceal bleeding — consider hepatology & transplant referral", {
    x: 0.3, y: 5.22, w: 9.4, h: 0.3,
    fontSize: 11, color: C.yellow, bold: true, fontFace: "Calibri", align: "center",
  });
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 14 — MEDICATIONS QUICK REFERENCE
// ──────────────────────────────────────────────────────────────────────────────
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  const s = pres.addSlide();
  bgRect(s);
  leftStripe(s, C.accent2);
  headerBar(s, "Pharmacological Management — Quick Reference", C.accent2);

  const drugs = [
    ["Drug", "Dose / Route", "Indication", "Notes"],
    ["Tranexamic Acid (TXA)", "1g IV over 10 min → 1g over 8h", "Hemorrhagic shock", "Within 3h of onset; anti-fibrinolytic"],
    ["Octreotide", "50 mcg IV bolus → 50 mcg/h infusion", "Variceal bleeding", "Reduces portal pressure"],
    ["Terlipressin", "1–2 mg IV q4–6h", "Variceal bleeding", "Superior to octreotide; not in all countries"],
    ["PPI (Pantoprazole)", "80 mg IV bolus → 8 mg/h infusion", "Peptic ulcer / non-variceal", "Pre- and post-endoscopy"],
    ["Ceftriaxone", "1g IV daily × 7 days", "Variceal + cirrhosis", "Prevents SBP, reduces rebleeding"],
    ["Vasopressin", "0.03–0.04 units/min IV", "Refractory hemorrhagic shock", "Bridge; give with nitroglycerin"],
    ["Norepinephrine", "0.01–3 mcg/kg/min IV", "Refractory shock, vasodilation", "Use after volume optimization"],
    ["FFP", "1:1:1 with pRBC + platelets", "Coagulopathy / MTP", "4 units FFP per 4 units pRBC"],
    ["Vitamin K", "10 mg IV (slow)", "Warfarin reversal", "Takes 6–12h; use 4-factor PCC urgently"],
    ["4-Factor PCC (KCentra)", "25–50 units/kg IV", "Urgent warfarin reversal", "Rapid reversal; give with Vitamin K"],
  ];

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        x, y, w: colW[ci], h: 0.42,
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        fontFace: "Calibri", align: ri === 0 ? "center" : "left", valign: "middle",
        margin: 4,
      });
    });
  });
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 15 — DISPOSITION & MONITORING
// ──────────────────────────────────────────────────────────────────────────────
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  bgRect(s);
  leftStripe(s, C.accent3);
  headerBar(s, "Disposition, Monitoring & Follow-up", C.accent3);

  const panels = [
    {
      title: "ICU ADMISSION CRITERIA",
      color: C.accent1,
      x: 0.3, y: 1.1, w: 4.4, h: 2.2,
      items: [
        "Class III or IV hemorrhagic shock",
        "Active variceal bleeding",
        "Age >60 + significant comorbidities",
        "Active ongoing transfusion requirements",
        "Post-emergency endoscopy or IR embolization",
        "Hemodynamic instability despite initial resuscitation",
        "Intubated patients",
      ],
    },
    {
      title: "CONTINUOUS MONITORING",
      color: C.accent3,
      x: 5.1, y: 1.1, w: 4.6, h: 2.2,
      items: [
        "Arterial line for continuous BP in severe shock",
        "Central venous catheter — CVP trending, vasoactive drugs",
        "Foley catheter — Urine output every hour",
        "Serial CBC, coags, lactate q2–4h until stable",
        "Pulse oximetry + capnography",
        "Repeat POCUS to reassess IVC / cardiac function",
        "ECG monitoring for arrhythmias",
      ],
    },
    {
      title: "DISCHARGE CRITERIA (Low-Risk GIB)",
      color: "1A5200",
      x: 0.3, y: 3.45, w: 4.4, h: 2.1,
      items: [
        "GBS score = 0: Low-risk — consider outpatient management",
        "Hemodynamically stable for ≥24h",
        "Hgb stable (not declining) ≥24h",
        "No high-risk endoscopic stigmata",
        "Reliable social support + close follow-up arranged",
        "Non-variceal source with successful hemostasis",
        "PPI therapy initiated",
      ],
    },
    {
      title: "SECONDARY PREVENTION",
      color: "7B2D8B",
      x: 5.1, y: 3.45, w: 4.6, h: 2.1,
      items: [
        "H. pylori testing and eradication if peptic ulcer",
        "PPI therapy long-term if NSAID use cannot be stopped",
        "Non-selective beta-blockers + EVL for varices",
        "Reduce alcohol / manage liver disease",
        "Anticoagulation reversal review — Balance thrombosis vs. bleeding",
        "Outpatient GI follow-up within 1–2 weeks",
        "Repeat endoscopy at 2–4 weeks for high-risk stigmata",
      ],
    },
  ];

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      x: p.x, y: p.y, w: p.w, h: 0.38,
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    });
  });
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 16 — SUMMARY ALGORITHM
// ──────────────────────────────────────────────────────────────────────────────
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  const s = pres.addSlide();
  bgRect(s, C.darkBg);
  headerBar(s, "Emergency Algorithm — GI Bleeding with Hypovolemic Shock", C.accent1);

  const alg = [
    { step: "PRESENTATION", text: "GI Bleeding + Hemodynamic Instability", color: C.accent1 },
    { step: "PRIMARY SURVEY", text: "Airway • Breathing • Circulation • 2 large-bore IVs • Labs • Monitor", color: "1A6091" },
    { step: "RESUSCITATE", text: "Warm crystalloid 1–2L → Blood products 1:1:1 → Activate MTP if needed → TXA 1g IV", color: "7B1E1E" },
    { step: "RISK STRATIFY", text: "Glasgow-Blatchford Score • Rockall • AIMS65 • Shock Index", color: "1A5200" },
    { step: "DIAGNOSE", text: "POCUS → NG tube → CT angiography (stable) → EGD within 12–24h", color: "7B4A00" },
    { step: "TREAT SOURCE", text: "Endoscopy (clips/cautery/bands) → IR embolization → Surgery if refractory", color: "7B2D8B" },
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// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 17 — KEY TAKEAWAYS
// ──────────────────────────────────────────────────────────────────────────────
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    "Hypovolemic shock from GI bleeding is a life-threatening emergency — act within minutes, not hours",
    "Tachycardia is the EARLIEST sign — hypotension is LATE and indicates >30% volume loss",
    "ATLS Class I–IV guides fluid/blood strategy: Class III+ requires blood products, not just crystalloid",
    "Activate MTP early: 1:1:1 (pRBC:FFP:Platelets) + TXA + calcium; avoid the lethal triad",
    "BUN:Cr ratio >30 distinguishes upper from lower GI source before endoscopy",
    "Variceal bleeding: Octreotide/terlipressin + prophylactic antibiotics + EGD within 12h + early TIPS",
    "Permissive hypotension (SBP 80–90) until source control — overresuscitation worsens coagulopathy",
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// ──────────────────────────────────────────────────────────────────────────────
// WRITE FILE
// ──────────────────────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/gi-shock-pptx/Hypovolemic_Shock_GI_Bleeding_EM.pptx" })
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