Critical ICU Management: Post-Partum Cardiac Arrest with Biventricular Failure, White-Out Chest, and ?Pneumothorax

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.3 x 7.5 inches — gives max real estate for a one-pager

// ─── Colour palette ───────────────────────────────────────────────────────────
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  header:    "C0392B",   // emergency red
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  col4:      "0F2233",   // deepest panel
  accent:    "E74C3C",   // red accent
  warn:      "F39C12",   // amber warning
  ok:        "27AE60",   // green tick
  white:     "FFFFFF",
  lt:        "D6EAF8",   // light blue text
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  gold:      "F1C40F",   // yellow highlight
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// ─── Full background ──────────────────────────────────────────────────────────
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slide.addText("AFE / BIVENTRICULAR FAILURE — ICU EMERGENCY CHECKLIST", {
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// Date label top-right
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// ─── COLUMN LAYOUT ────────────────────────────────────────────────────────────
// 5 columns: [0] Pneumothorax  [1] Ventilator  [2] Vasopressors  [3] Coags/DIC  [4] ECMO/Escalate
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const colY = 0.63;
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const gap  = 0.065;
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const borderColors = [C.accent, "2980B9", "27AE60", C.warn, "8E44AD"];
const headerBg     = [C.accent, "2980B9", "27AE60", C.warn, "8E44AD"];

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// ─── COLUMN HEADERS ───────────────────────────────────────────────────────────
const headers = [
  "① PNEUMOTHORAX",
  "② VENTILATOR",
  "③ VASOPRESSORS",
  "④ DIC / COAGS",
  "⑤ ECMO / ESCALATE",
];
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// ─── HELPER: add bullet lines ─────────────────────────────────────────────────
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// ─── HELPER: add a drug box ───────────────────────────────────────────────────
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// ═══════════════════════════════════════════════════════════════════════════════
// COLUMN 0: PNEUMOTHORAX
// ═══════════════════════════════════════════════════════════════════════════════
let y0 = colY + 0.47;

sectionLabel(0, y0, "▶  RULE OUT FIRST — DO NOT DELAY", C.accent);
y0 += 0.26;

bullets(0, y0, [
  { text:"POCUS both lungs: absent sliding = PTX", urgent:true },
  { text:"Barcode sign on M-mode", urgent:true },
  { text:"Check peak airway pressure (↑ = obstruction)", urgent:true },
], { h:0.66 });
y0 += 0.68;

sectionLabel(0, y0, "IF UNSTABLE — ACT IMMEDIATELY", C.accent);
y0 += 0.26;

bullets(0, y0, [
  { text:"Needle decomp: 2nd ICS MCL bilaterally", urgent:true, bold:true },
  { text:"Then bilateral ICC 28-32F (safe side)", urgent:true },
  { text:"Do NOT wait for CT if hemodynamically unstable", urgent:true },
], { h:0.72 });
y0 += 0.74;

sectionLabel(0, y0, "POST-DRAIN CHECKS", "2980B9");
y0 += 0.26;
bullets(0, y0, [
  { text:"Repeat CXR — confirm re-expansion" },
  { text:"Water seal drain — watch for air leak" },
  { text:"Peak Paw should fall if PTX drained" },
  { text:"Repeat POCUS after drain insertion" },
], { h:0.76 });
y0 += 0.78;

sectionLabel(0, y0, "MONITORING TARGETS", "27AE60");
y0 += 0.26;
bullets(0, y0, [
  { text:"MAP ≥ 65 mmHg (aim 70 post-partum)", ok:true },
  { text:"SpO2 ≥ 92% / PaO2 > 60 mmHg", ok:true },
  { text:"Peak Paw < 35 cmH2O", ok:true },
  { text:"Plateau P < 30 / Driving P < 15", ok:true },
], { h:0.76 });

// ═══════════════════════════════════════════════════════════════════════════════
// COLUMN 1: VENTILATOR
// ═══════════════════════════════════════════════════════════════════════════════
let y1 = colY + 0.47;

sectionLabel(1, y1, "LUNG-PROTECTIVE SETTINGS (ARDSnet)", "2980B9");
y1 += 0.26;
bullets(1, y1, [
  { text:"Tidal volume: 4–6 ml/kg IBW (NOT actual BW)" },
  { text:"PEEP: 8–12 cmH2O (avoid >14 → worsens RV)" },
  { text:"FiO2: 1.0 initially, wean guided by SpO2/ABG" },
  { text:"Mode: Volume AC or Pressure AC" },
  { text:"RR: 18–22/min; adjust for PaCO2" },
], { h:0.9 });
y1 += 0.92;

sectionLabel(1, y1, "CAUTION IN BIVENTRICULAR FAILURE", C.warn);
y1 += 0.26;
bullets(1, y1, [
  { text:"High PEEP → ↑ RV afterload → avoid", warn:true },
  { text:"Hypercapnia → ↑ PVR → worsen RV → keep PaCO2 35–45", warn:true },
  { text:"Permissive hypercapnia only if driving P high", warn:true },
], { h:0.68 });
y1 += 0.7;

sectionLabel(1, y1, "PRONING — Consider if P/F < 150", "8E44AD");
y1 += 0.26;
bullets(1, y1, [
  { text:"Prone for ≥ 16 hrs/session (PROSEVA protocol)" },
  { text:"Improves V/Q mismatch in white-out ARDS" },
  { text:"Re-assess echo post-proning (RV preload shifts)" },
], { h:0.65 });
y1 += 0.67;

sectionLabel(1, y1, "BRONCHOSCOPY / AIRWAY", "2980B9");
y1 += 0.26;
bullets(1, y1, [
  { text:"Consider bronchoscopy if unilateral worsening" },
  { text:"Exclude mucus plugging / main bronchus intubation" },
  { text:"Lavage for cytology (squamous cells → AFE)" },
  { text:"Suction secretions, avoid prolonged disconnection" },
], { h:0.76 });
y1 += 0.78;

sectionLabel(1, y1, "ABG TARGETS", "27AE60");
y1 += 0.26;
bullets(1, y1, [
  { text:"pH 7.30–7.45", ok:true },
  { text:"PaO2 60–80 mmHg (FiO2 weaning when >80)", ok:true },
  { text:"PaCO2 35–45 (strict in RV failure)", ok:true },
], { h:0.62 });

// ═══════════════════════════════════════════════════════════════════════════════
// COLUMN 2: VASOPRESSORS
// ═══════════════════════════════════════════════════════════════════════════════
let y2 = colY + 0.47;

sectionLabel(2, y2, "CURRENT: NorAdr + Adr + Vasopressin", "27AE60");
y2 += 0.26;

drugBox(2, y2, "NORADRENALINE (1st line vasopressor)", "0.05–1.0 mcg/kg/min\nTarget MAP ≥65; caution: ↑PVR at high doses", "2980B9");
y2 += 0.5;

drugBox(2, y2, "ADRENALINE (inotrope + vasopressor)", "0.05–0.5 mcg/kg/min\nFor biventricular failure; watch tachyarrhythmia", "E74C3C");
y2 += 0.5;

drugBox(2, y2, "VASOPRESSIN (RV-sparing vasopressor)", "0.03–0.04 units/min (fixed dose)\nDoes NOT ↑PVR — preferred in RV failure", "27AE60");
y2 += 0.5;

sectionLabel(2, y2, "ADD NOW: PULMONARY VASODILATORS", C.warn);
y2 += 0.26;

drugBox(2, y2, "INHALED NITRIC OXIDE (iNO) — PRIORITY", "20–40 ppm via ventilator circuit\nSelective ↓PVR, improves RV unloading", C.warn);
y2 += 0.5;

drugBox(2, y2, "INHALED ILOPROST (if iNO unavailable)", "2.5–5 mcg nebulised q2h via circuit\nProstacyclin analogue, ↓PVR", "9B59B6");
y2 += 0.5;

drugBox(2, y2, "SILDENAFIL (oral/NG — if above unavailable)", "25 mg q6h via NG tube\nPDE5 inhibitor, ↓PVR — monitor systemic BP", "1ABC9C");
y2 += 0.5;

sectionLabel(2, y2, "AVOID", C.accent);
y2 += 0.26;
bullets(2, y2, [
  { text:"High-dose noradrenaline alone → worsens RV", urgent:true },
  { text:"Aggressive fluid boluses → dilates RV further", urgent:true },
  { text:"rFVIIa in AFE-DIC → organ thrombosis risk", urgent:true },
], { h:0.62 });

// ═══════════════════════════════════════════════════════════════════════════════
// COLUMN 3: DIC / COAGULATION
// ═══════════════════════════════════════════════════════════════════════════════
let y3 = colY + 0.47;

sectionLabel(3, y3, "URGENT LABS — SEND NOW", C.warn);
y3 += 0.26;
bullets(3, y3, [
  { text:"PT, APTT, fibrinogen, D-dimer", warn:true },
  { text:"CBC with platelet count + blood film", warn:true },
  { text:"TEG or ROTEM (bedside, results in 10 min)", warn:true },
  { text:"Group & crossmatch; activate MTP", warn:true },
  { text:"Troponin, BNP, LFTs, creatinine, lactate", warn:true },
  { text:"Blood cultures ×2 before antibiotics", warn:true },
], { h:1.0 });
y3 += 1.02;

sectionLabel(3, y3, "MASSIVE TRANSFUSION PROTOCOL (MTP)", "E74C3C");
y3 += 0.26;
bullets(3, y3, [
  { text:"pRBC : FFP : Platelets = 1:1:1 ratio", bold:true },
  { text:"Cryoprecipitate if fibrinogen < 1.5 g/L (AFE depletes fibrinogen profoundly)" },
  { text:"Platelet transfusion if count < 50 × 10⁹/L" },
  { text:"Calcium gluconate 10ml 10% per 4 units pRBC" },
], { h:0.9 });
y3 += 0.92;

sectionLabel(3, y3, "TEG/ROTEM GUIDED TARGETS", "27AE60");
y3 += 0.26;
bullets(3, y3, [
  { text:"Fibrinogen (Clauss) > 2.0 g/L", ok:true },
  { text:"Platelet count > 50 × 10⁹/L", ok:true },
  { text:"PT ratio < 1.5", ok:true },
  { text:"APTT < 45 sec", ok:true },
], { h:0.72 });
y3 += 0.74;

sectionLabel(3, y3, "SPECIFIC AGENTS", "9B59B6");
y3 += 0.26;

drugBox(3, y3, "TRANEXAMIC ACID (TXA)", "1g IV over 10 min, then 1g over 8h\nFor hemorrhage; caution if thrombosis signs", "9B59B6");
y3 += 0.5;

sectionLabel(3, y3, "⚠ DO NOT USE rFVIIa in AFE", C.accent);
y3 += 0.26;
bullets(3, y3, [
  { text:"Systematic review: ↑ organ thrombosis + death in AFE-DIC", urgent:true, bold:true },
], { h:0.32 });
y3 += 0.34;

sectionLabel(3, y3, "UTERINE HEMORRHAGE CONTROL", C.warn);
y3 += 0.26;
bullets(3, y3, [
  { text:"Oxytocin 40 units in 500ml NS @125ml/h" },
  { text:"Ergometrine 0.25mg IM (if no hypertension)" },
  { text:"Carboprost (15-methyl PGF2α) 0.25mg IM q15min" },
  { text:"Uterine balloon tamponade if bleeding continues" },
], { h:0.76 });

// ═══════════════════════════════════════════════════════════════════════════════
// COLUMN 4: ECMO / ESCALATE
// ═══════════════════════════════════════════════════════════════════════════════
let y4 = colY + 0.47;

sectionLabel(4, y4, "ECMO INDICATIONS — MET IN THIS PATIENT", "8E44AD");
y4 += 0.26;
bullets(4, y4, [
  { text:"Post-cardiac arrest (prolonged CPR)", bold:true },
  { text:"Biventricular dilation/failure on echo" },
  { text:"Refractory shock on ≥ 3 vasopressors" },
  { text:"Bilateral ARDS (bilateral white-out, P/F < 150)" },
  { text:"AFE with severe ventricular dysfunction" },
], { h:0.88 });
y4 += 0.9;

// VA-ECMO box
slide.addShape(pres.ShapeType.rect, {
  x: cols[4]+0.06, y: y4, w: colW-0.12, h: 0.62,
  fill: { color: "8E44AD"+"44" },
  line: { color: "8E44AD", pt: 2 },
});
slide.addText([
  { text: "▶ VA-ECMO PREFERRED", options: { bold:true, color:"CE9BF5", fontSize:8.5, breakLine:true } },
  { text: "Provides BOTH cardiac + respiratory support\nPeripheral cannulation: Femoral A (15-19F) + Femoral V (19-25F)\nActivate ECMO team NOW — do not delay", options: { color:C.white, fontSize:6.5 } },
], {
  x: cols[4]+0.1, y: y4+0.04, w: colW-0.18, h: 0.55,
  fontFace:"Arial", valign:"top", margin:0,
});
y4 += 0.66;

sectionLabel(4, y4, "ECHO ASSESSMENT (TEE/TTE)", "2980B9");
y4 += 0.26;
bullets(4, y4, [
  { text:"RV:LV ratio > 0.9 → severe RV dilation" },
  { text:"TAPSE < 17mm → RV dysfunction" },
  { text:"IVS D-sign → septal shift, RV pressure overload" },
  { text:"LV EF → if <35% biventricular failure confirmed" },
  { text:"Pericardial effusion → rule out tamponade" },
  { text:"IVC collapsibility → volume status guide" },
], { h:1.0 });
y4 += 1.02;

sectionLabel(4, y4, "INVESTIGATIONS CHECKLIST", C.warn);
y4 += 0.26;
bullets(4, y4, [
  { text:"CXR post-drains (lung re-expansion)", warn:true },
  { text:"Repeat ABG at 30 min" },
  { text:"CT-PA when stable (exclude PE)", warn:true },
  { text:"Repeat TEE/TTE every 4–6 hrs" },
  { text:"Serum troponin + BNP serial" },
], { h:0.84 });
y4 += 0.86;

sectionLabel(4, y4, "WHEN TO CALL FOR HELP", C.accent);
y4 += 0.26;
bullets(4, y4, [
  { text:"ECMO team if not available on-site", urgent:true },
  { text:"Maternal-fetal medicine / obstetric HDU" },
  { text:"Cardiothoracic surgery if ECMO needed" },
  { text:"Haematology for refractory DIC" },
], { h:0.72 });

// ─── FOOTER ──────────────────────────────────────────────────────────────────
slide.addShape(pres.ShapeType.rect, { x:0, y:7.3, w:13.3, h:0.2, fill:{color:"0A1520"}, line:{color:"0A1520"} });
slide.addText(
  "AFE Diagnosis Criteria: Cardiopulmonary arrest/hypotension + Respiratory compromise + DIC + Onset during/within 30 min of delivery + Afebrile  |  Evidence: Creasy & Resnik MFM · Murray & Nadel Respiratory Medicine · Fishman's Pulmonary Diseases · Miller's Anesthesia 10e",
  {
    x:0.1, y:7.3, w:11.0, h:0.2,
    fontSize:5, color:C.muted, fontFace:"Arial",
    align:"left", valign:"middle", margin:0,
  }
);
slide.addText("For ICU Use — Emergency Reference Only", {
  x:11.1, y:7.3, w:2.1, h:0.2,
  fontSize:5, color:C.accent, fontFace:"Arial",
  align:"right", valign:"middle", margin:0,
});

// ─── WRITE ────────────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/afe-checklist/AFE_ICU_Checklist.pptx" })
  .then(() => console.log("DONE: /home/daytona/workspace/afe-checklist/AFE_ICU_Checklist.pptx"))
  .catch(e => { console.error(e); process.exit(1); });

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