@erosolaraijs/cure 2.3.1 → 2.5.0

package/dist/capabilities/emergencyOncology.js

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+/**
+ * Emergency Oncology and Oncologic Emergencies Protocols
+ *
+ * ╔═══════════════════════════════════════════════════════════════════════════════╗
+ * ║  EMERGENCY ONCOLOGY - LIFE-SAVING INTERVENTIONS FOR CANCER EMERGENCIES       ║
+ * ╠═══════════════════════════════════════════════════════════════════════════════╣
+ * ║  This module provides protocols for:                                          ║
+ * ║  - Structural emergencies (SVC syndrome, spinal cord compression, etc.)      ║
+ * ║  - Metabolic emergencies (TLS, hypercalcemia, SIADH, etc.)                   ║
+ * ║  - Treatment-related emergencies (febrile neutropenia, CRS, irAEs)           ║
+ * ║  - Extravasation and infusion reactions                                       ║
+ * ║  - Hemorrhagic and thrombotic emergencies                                    ║
+ * ║  - Rapid-onset symptoms requiring immediate intervention                      ║
+ * ╚═══════════════════════════════════════════════════════════════════════════════╝
+ */
+// ═══════════════════════════════════════════════════════════════════════════════
+// STRUCTURAL EMERGENCIES
+// ═══════════════════════════════════════════════════════════════════════════════
+export const STRUCTURAL_EMERGENCIES = [
+    {
+        id: 'spinal-cord-compression',
+        name: 'Malignant Spinal Cord Compression (MSCC)',
+        category: 'Structural',
+        urgency: 'Immediate',
+        timeToIntervention: 'Within 24 hours (ideally <6 hours)',
+        recognition: {
+            symptoms: [
+                'Back pain (90%) - often precedes neurologic symptoms by weeks',
+                'Progressive weakness in legs',
+                'Sensory changes (numbness, paresthesias)',
+                'Urinary retention or incontinence',
+                'Constipation or fecal incontinence'
+            ],
+            signs: [
+                'Motor weakness (usually bilateral)',
+                'Sensory level',
+                'Hyperreflexia below level, hyporeflexia at level',
+                'Positive Babinski',
+                'Decreased anal tone',
+                'Palpable bladder'
+            ],
+            diagnosticCriteria: [
+                'Clinical suspicion + MRI confirmation',
+                'Epidural tumor with thecal sac compression',
+                'May have cord edema or myelomalacia'
+            ],
+            imagingFindings: [
+                'MRI whole spine (gold standard)',
+                'Epidural mass',
+                'Cord compression or displacement',
+                'Vertebral body destruction',
+                'Paraspinal mass extension'
+            ],
+            riskFactors: [
+                'Known spine metastases',
+                'Breast, prostate, lung, kidney, myeloma',
+                'Prior radiation to spine'
+            ]
+        },
+        initialManagement: [
+            {
+                step: 1,
+                action: 'High-dose corticosteroids',
+                timing: 'Immediately upon clinical suspicion',
+                details: 'Do not wait for MRI to start steroids if clinical suspicion high',
+                medications: [{
+                        drug: 'Dexamethasone',
+                        dose: '10-16mg IV bolus, then 4-6mg IV/PO q6h',
+                        route: 'IV then PO',
+                        frequency: 'Every 6 hours',
+                        duration: 'Until definitive treatment, then taper',
+                        monitoring: 'Blood glucose, GI prophylaxis'
+                    }]
+            },
+            {
+                step: 2,
+                action: 'Urgent MRI whole spine',
+                timing: 'Within 4 hours',
+                details: 'Include entire spine - multiple levels in 10-38%'
+            },
+            {
+                step: 3,
+                action: 'Bladder management',
+                timing: 'If retention present',
+                details: 'Foley catheter if urinary retention'
+            },
+            {
+                step: 4,
+                action: 'Pain control',
+                timing: 'Concurrent',
+                details: 'Adequate analgesia, consider PCA if needed'
+            },
+            {
+                step: 5,
+                action: 'VTE prophylaxis',
+                timing: 'If no contraindication',
+                details: 'Mechanical ± pharmacologic (consider bleeding risk)'
+            }
+        ],
+        definitiveManagement: [
+            {
+                intervention: 'Surgical decompression + stabilization',
+                indication: 'Single level, good PS (ECOG 0-2), life expectancy >3 months, radiosensitive tumor, spinal instability',
+                timing: 'Within 24-48 hours',
+                expectedOutcome: '80% maintain/regain ambulation if ambulatory at surgery',
+                alternatives: ['Radiation alone if poor surgical candidate']
+            },
+            {
+                intervention: 'Radiation therapy (conventional or SBRT)',
+                indication: 'Multiple levels, radiosensitive tumor, poor surgical candidate',
+                timing: 'Within 24 hours of diagnosis',
+                expectedOutcome: '70% pain relief, 30-50% neurologic improvement'
+            },
+            {
+                intervention: 'Surgery followed by radiation',
+                indication: 'Standard approach for most patients',
+                timing: 'RT 2-4 weeks post-op',
+                expectedOutcome: 'Best outcomes in randomized trial (Patchell)'
+            }
+        ],
+        monitoring: {
+            parameters: ['Neurologic exam q4h', 'Pain score', 'Bladder function', 'Blood glucose'],
+            frequency: 'Every 4-6 hours initially',
+            escalationCriteria: ['Progressive weakness', 'New bowel/bladder symptoms', 'Ascending sensory level'],
+            deescalationCriteria: ['Stable or improving neuro exam', 'Completed definitive treatment']
+        },
+        outcomes: {
+            withTreatment: '75-90% maintain ambulation if treated while ambulatory',
+            withoutTreatment: 'Paraplegia within hours to days',
+            longTermPrognosis: 'Dependent on primary tumor, extent of disease, pre-treatment function'
+        },
+        preventionStrategies: [
+            'Early imaging for cancer patients with new back pain',
+            'Bone-modifying agents for bone metastases',
+            'Prophylactic spine radiation in high-risk lesions'
+        ]
+    },
+    {
+        id: 'svc-syndrome',
+        name: 'Superior Vena Cava (SVC) Syndrome',
+        category: 'Structural',
+        urgency: 'Urgent',
+        timeToIntervention: 'Within 24-72 hours (immediate if stridor/cerebral edema)',
+        recognition: {
+            symptoms: [
+                'Facial swelling/plethora (82%)',
+                'Arm swelling (68%)',
+                'Dyspnea (54%)',
+                'Cough',
+                'Headache (worse when bending forward)',
+                'Chest pain',
+                'Dysphagia'
+            ],
+            signs: [
+                'Dilated neck and chest wall veins',
+                'Facial edema and cyanosis',
+                'Upper extremity edema',
+                'Pemberton sign (facial congestion with arm elevation)',
+                'Papilledema (if cerebral edema)'
+            ],
+            diagnosticCriteria: [
+                'Clinical syndrome + imaging confirmation',
+                'CT chest with contrast showing SVC obstruction'
+            ],
+            imagingFindings: [
+                'CT chest with IV contrast (first-line)',
+                'SVC narrowing or occlusion',
+                'Collateral vessel formation',
+                'Mediastinal mass',
+                'Thrombus if present'
+            ],
+            riskFactors: [
+                'Lung cancer (most common - 80%)',
+                'Lymphoma',
+                'Metastatic disease',
+                'Central venous catheter/device'
+            ]
+        },
+        initialManagement: [
+            {
+                step: 1,
+                action: 'Assess airway',
+                timing: 'Immediate',
+                details: 'Stridor requires emergent intervention'
+            },
+            {
+                step: 2,
+                action: 'Head elevation',
+                timing: 'Immediate',
+                details: 'Elevate head of bed 45-90 degrees'
+            },
+            {
+                step: 3,
+                action: 'Oxygen',
+                timing: 'If hypoxic',
+                details: 'Supplemental O2 to maintain SpO2 >92%'
+            },
+            {
+                step: 4,
+                action: 'Corticosteroids (if lymphoma/thymoma suspected)',
+                timing: 'After tissue diagnosis if possible',
+                details: 'May obscure diagnosis in lymphoma - get tissue first if stable',
+                medications: [{
+                        drug: 'Dexamethasone',
+                        dose: '4mg IV q6h',
+                        route: 'IV',
+                        frequency: 'Every 6 hours',
+                        duration: 'Until treatment response',
+                        monitoring: 'Blood glucose'
+                    }],
+                contraindications: ['Do not give before biopsy if lymphoma suspected and patient stable']
+            },
+            {
+                step: 5,
+                action: 'Tissue diagnosis',
+                timing: 'Urgent but safe',
+                details: 'Bronchoscopy, mediastinoscopy, CT-guided biopsy, thoracentesis, node biopsy'
+            }
+        ],
+        definitiveManagement: [
+            {
+                intervention: 'Endovascular stenting',
+                indication: 'Severe symptoms, NSCLC, recurrent after radiation',
+                timing: 'Within 24-48 hours',
+                expectedOutcome: '95% symptom relief within 72 hours',
+                alternatives: ['Radiation', 'Systemic therapy']
+            },
+            {
+                intervention: 'Radiation therapy',
+                indication: 'Radiosensitive tumors (SCLC, lymphoma)',
+                timing: 'Start within 24-48 hours',
+                expectedOutcome: '70-90% response in 2 weeks'
+            },
+            {
+                intervention: 'Chemotherapy',
+                indication: 'Chemosensitive tumors (SCLC, lymphoma, germ cell)',
+                timing: 'Start immediately after diagnosis',
+                expectedOutcome: 'Rapid response in chemo-sensitive tumors'
+            },
+            {
+                intervention: 'Anticoagulation',
+                indication: 'Thrombus present',
+                timing: 'If thrombus confirmed',
+                expectedOutcome: 'Prevents clot propagation'
+            }
+        ],
+        monitoring: {
+            parameters: ['Respiratory status', 'Oxygen saturation', 'Facial/arm swelling', 'Mental status'],
+            frequency: 'Every 4-6 hours',
+            escalationCriteria: ['Stridor', 'Decreasing O2 sat', 'Altered mental status', 'Progressive symptoms'],
+            deescalationCriteria: ['Symptom improvement', 'Decreased swelling']
+        },
+        outcomes: {
+            withTreatment: 'Symptom relief in 70-90% within 1-2 weeks',
+            withoutTreatment: 'Progressive symptoms, risk of cerebral edema',
+            longTermPrognosis: 'Dependent on underlying malignancy'
+        },
+        preventionStrategies: [
+            'Early treatment of mediastinal tumors',
+            'Careful CVC placement and maintenance'
+        ]
+    },
+    {
+        id: 'malignant-pericardial-effusion',
+        name: 'Malignant Pericardial Effusion / Cardiac Tamponade',
+        category: 'Cardiovascular',
+        urgency: 'Immediate',
+        timeToIntervention: 'Within hours if tamponade',
+        recognition: {
+            symptoms: [
+                'Dyspnea (most common)',
+                'Chest pain/pressure',
+                'Orthopnea',
+                'Fatigue',
+                'Cough',
+                'Anxiety'
+            ],
+            signs: [
+                'Beck\'s triad (hypotension, JVD, muffled heart sounds)',
+                'Tachycardia',
+                'Pulsus paradoxus >10 mmHg',
+                'Kussmaul sign',
+                'Electrical alternans on ECG'
+            ],
+            diagnosticCriteria: [
+                'Echocardiogram showing effusion ± RA/RV diastolic collapse',
+                'CT showing pericardial thickening/fluid'
+            ],
+            labFindings: ['Elevated troponin possible', 'Low voltage on ECG'],
+            imagingFindings: [
+                'Echo: pericardial effusion, RA/RV collapse, IVC plethora',
+                'CT: pericardial fluid, may see tumor implants'
+            ],
+            riskFactors: [
+                'Lung cancer (most common)',
+                'Breast cancer',
+                'Lymphoma/leukemia',
+                'Melanoma',
+                'Prior chest radiation'
+            ]
+        },
+        initialManagement: [
+            {
+                step: 1,
+                action: 'IV access and monitoring',
+                timing: 'Immediate',
+                details: 'Continuous cardiac monitoring, large bore IV access'
+            },
+            {
+                step: 2,
+                action: 'Volume resuscitation',
+                timing: 'If hypotensive',
+                details: 'Fluid bolus to maintain preload',
+                medications: [{
+                        drug: 'Normal saline',
+                        dose: '500-1000mL bolus',
+                        route: 'IV',
+                        frequency: 'As needed',
+                        duration: 'Until stabilized',
+                        monitoring: 'BP, JVP, urine output'
+                    }]
+            },
+            {
+                step: 3,
+                action: 'Avoid negative inotropes',
+                timing: 'Ongoing',
+                details: 'Avoid beta-blockers, calcium channel blockers'
+            },
+            {
+                step: 4,
+                action: 'Urgent echocardiogram',
+                timing: 'Within 1 hour if unstable',
+                details: 'Confirm diagnosis and guide drainage'
+            }
+        ],
+        definitiveManagement: [
+            {
+                intervention: 'Pericardiocentesis',
+                indication: 'Hemodynamic compromise, large effusion',
+                timing: 'Emergent if tamponade physiology',
+                expectedOutcome: 'Immediate hemodynamic improvement',
+                alternatives: ['Surgical window if recurrent']
+            },
+            {
+                intervention: 'Pericardial window',
+                indication: 'Recurrent effusions, loculated fluid',
+                timing: 'After initial stabilization',
+                expectedOutcome: 'Prevents recurrence in 85-90%'
+            },
+            {
+                intervention: 'Pericardial sclerosis',
+                indication: 'Recurrent effusions',
+                timing: 'After drainage',
+                expectedOutcome: 'Reduces recurrence'
+            },
+            {
+                intervention: 'Systemic therapy',
+                indication: 'Chemosensitive tumor',
+                timing: 'After stabilization',
+                expectedOutcome: 'May prevent recurrence'
+            }
+        ],
+        monitoring: {
+            parameters: ['Vital signs', 'JVP', 'Pulsus paradoxus', 'Urine output', 'Drain output'],
+            frequency: 'Continuous initially, then q4h',
+            escalationCriteria: ['Hemodynamic instability', 'Reaccumulation', 'Drain malfunction'],
+            deescalationCriteria: ['Stable hemodynamics', 'Minimal drain output', 'No reaccumulation on echo']
+        },
+        outcomes: {
+            withTreatment: 'Immediate relief of tamponade, 50% recurrence without definitive procedure',
+            withoutTreatment: 'Cardiovascular collapse and death',
+            longTermPrognosis: 'Median survival 3-6 months (dependent on primary tumor)'
+        },
+        preventionStrategies: [
+            'Surveillance echo in high-risk patients',
+            'Systemic therapy for responsive tumors'
+        ]
+    },
+    {
+        id: 'malignant-airway-obstruction',
+        name: 'Malignant Airway Obstruction',
+        category: 'Respiratory',
+        urgency: 'Immediate',
+        timeToIntervention: 'Within hours',
+        recognition: {
+            symptoms: [
+                'Progressive dyspnea',
+                'Stridor',
+                'Wheezing',
+                'Cough',
+                'Hemoptysis',
+                'Inability to lie flat'
+            ],
+            signs: [
+                'Stridor (inspiratory = extrathoracic, expiratory = intrathoracic)',
+                'Use of accessory muscles',
+                'Cyanosis',
+                'Tracheal deviation',
+                'Decreased breath sounds'
+            ],
+            diagnosticCriteria: [
+                'Clinical symptoms + imaging/bronchoscopy confirmation',
+                '>50% obstruction typically symptomatic'
+            ],
+            imagingFindings: [
+                'CT chest: airway narrowing, intraluminal mass, extrinsic compression',
+                'Bronchoscopy: direct visualization'
+            ],
+            riskFactors: [
+                'Lung cancer (most common)',
+                'Metastatic disease to airways',
+                'Thyroid cancer',
+                'Esophageal cancer'
+            ]
+        },
+        initialManagement: [
+            {
+                step: 1,
+                action: 'Airway assessment',
+                timing: 'Immediate',
+                details: 'Prepare for potential difficult airway'
+            },
+            {
+                step: 2,
+                action: 'Heliox',
+                timing: 'If available',
+                details: 'Helium-oxygen mixture reduces airway resistance',
+                medications: [{
+                        drug: 'Heliox 80:20 or 70:30',
+                        dose: 'Continuous inhalation',
+                        route: 'Inhalation',
+                        frequency: 'Continuous',
+                        duration: 'Until definitive treatment',
+                        monitoring: 'Work of breathing, O2 sat'
+                    }]
+            },
+            {
+                step: 3,
+                action: 'Corticosteroids',
+                timing: 'Immediately',
+                details: 'Reduce peritumoral edema',
+                medications: [{
+                        drug: 'Dexamethasone',
+                        dose: '8-10mg IV',
+                        route: 'IV',
+                        frequency: 'Q6-8h',
+                        duration: 'Until intervention',
+                        monitoring: 'Blood glucose'
+                    }]
+            },
+            {
+                step: 4,
+                action: 'Nebulized racemic epinephrine',
+                timing: 'If stridor',
+                details: 'Reduces mucosal edema',
+                medications: [{
+                        drug: 'Racemic epinephrine 2.25%',
+                        dose: '0.5mL in 3mL NS',
+                        route: 'Nebulized',
+                        frequency: 'Q20 min x 3 prn',
+                        duration: 'As needed',
+                        monitoring: 'HR, BP, tremor'
+                    }]
+            }
+        ],
+        definitiveManagement: [
+            {
+                intervention: 'Rigid bronchoscopy with debulking',
+                indication: 'Intraluminal tumor',
+                timing: 'Emergent if severe obstruction',
+                expectedOutcome: 'Immediate airway patency'
+            },
+            {
+                intervention: 'Airway stenting',
+                indication: 'Extrinsic compression or post-debulking',
+                timing: 'At time of bronchoscopy',
+                expectedOutcome: 'Maintains airway patency'
+            },
+            {
+                intervention: 'Laser/electrocautery/cryotherapy',
+                indication: 'Intraluminal tumor ablation',
+                timing: 'At bronchoscopy',
+                expectedOutcome: 'Tumor debulking'
+            },
+            {
+                intervention: 'External beam radiation',
+                indication: 'Radiosensitive tumor, not emergent',
+                timing: 'After initial stabilization',
+                expectedOutcome: 'Tumor shrinkage over weeks'
+            }
+        ],
+        monitoring: {
+            parameters: ['Respiratory rate', 'O2 saturation', 'Stridor', 'Work of breathing'],
+            frequency: 'Continuous initially',
+            escalationCriteria: ['Worsening stridor', 'Desaturation', 'Fatigue', 'Altered mental status'],
+            deescalationCriteria: ['Improved breathing', 'No stridor', 'Stable oxygenation']
+        },
+        outcomes: {
+            withTreatment: '85-90% immediate symptom relief with intervention',
+            withoutTreatment: 'Respiratory failure and death',
+            longTermPrognosis: 'Dependent on ability to treat underlying cancer'
+        },
+        preventionStrategies: [
+            'Early treatment of central lung tumors',
+            'Surveillance bronchoscopy in high-risk patients'
+        ]
+    }
+];
+// ═══════════════════════════════════════════════════════════════════════════════
+// METABOLIC EMERGENCIES
+// ═══════════════════════════════════════════════════════════════════════════════
+export const METABOLIC_EMERGENCIES = [
+    {
+        id: 'tumor-lysis-syndrome',
+        name: 'Tumor Lysis Syndrome (TLS)',
+        category: 'Metabolic',
+        urgency: 'Urgent',
+        timeToIntervention: 'Within hours',
+        recognition: {
+            symptoms: [
+                'Nausea/vomiting',
+                'Diarrhea',
+                'Muscle cramps/tetany',
+                'Weakness',
+                'Lethargy/confusion',
+                'Seizures',
+                'Arrhythmias',
+                'Oliguria/anuria'
+            ],
+            signs: [
+                'Cardiac arrhythmias (peaked T waves, QRS widening)',
+                'Chvostek and Trousseau signs (hypocalcemia)',
+                'Muscle weakness',
+                'Decreased urine output'
+            ],
+            diagnosticCriteria: [
+                'Cairo-Bishop criteria:',
+                'Laboratory TLS: ≥2 of: uric acid ≥8 or 25% increase, K ≥6 or 25% increase, phosphate ≥4.5 (peds ≥6.5) or 25% increase, calcium ≤7 or 25% decrease',
+                'Clinical TLS: Lab TLS + creatinine ≥1.5x ULN, arrhythmia, seizure, or death'
+            ],
+            labFindings: [
+                'Hyperuricemia (>8 mg/dL)',
+                'Hyperkalemia (>6 mEq/L)',
+                'Hyperphosphatemia (>4.5 mg/dL)',
+                'Hypocalcemia (<7 mg/dL)',
+                'Elevated creatinine',
+                'Elevated LDH'
+            ],
+            riskFactors: [
+                'High tumor burden (bulky lymphoma, ALL, AML with high WBC)',
+                'High proliferative rate',
+                'Chemosensitive tumor',
+                'Pre-existing renal dysfunction',
+                'Elevated LDH, uric acid at baseline'
+            ]
+        },
+        initialManagement: [
+            {
+                step: 1,
+                action: 'Aggressive IV hydration',
+                timing: 'Immediately',
+                details: 'Goal urine output 80-100 mL/m²/hour (2-3 L/m²/day)',
+                medications: [{
+                        drug: 'Normal saline or D5W 1/2NS',
+                        dose: '200-250 mL/hr (or 3L/m²/day)',
+                        route: 'IV',
+                        frequency: 'Continuous',
+                        duration: 'Until TLS resolved',
+                        monitoring: 'I/Os, weight, creatinine'
+                    }]
+            },
+            {
+                step: 2,
+                action: 'Rasburicase (if high risk or established TLS)',
+                timing: 'Immediately if indicated',
+                details: 'Contraindicated in G6PD deficiency',
+                medications: [{
+                        drug: 'Rasburicase',
+                        dose: '0.2 mg/kg (single dose often sufficient)',
+                        route: 'IV over 30 min',
+                        frequency: 'Once (may repeat)',
+                        duration: 'Single dose',
+                        monitoring: 'Uric acid (draw on ice), watch for hemolysis'
+                    }],
+                contraindications: ['G6PD deficiency', 'History of severe hypersensitivity']
+            },
+            {
+                step: 3,
+                action: 'Allopurinol (if intermediate risk, rasburicase contraindicated)',
+                timing: 'Before chemotherapy',
+                details: 'Less effective than rasburicase for established TLS',
+                medications: [{
+                        drug: 'Allopurinol',
+                        dose: '100 mg/m² PO TID (max 800mg/day) or 200-400mg/m²/day IV',
+                        route: 'PO or IV',
+                        frequency: 'TID or divided',
+                        duration: 'Continue 3-7 days post-chemo',
+                        monitoring: 'Uric acid, rash'
+                    }]
+            },
+            {
+                step: 4,
+                action: 'Hyperkalemia management',
+                timing: 'If K >6 or ECG changes',
+                details: 'Cardiac protection, shift, elimination',
+                medications: [
+                    { drug: 'Calcium gluconate 10%', dose: '10 mL IV over 2-3 min', route: 'IV', frequency: 'PRN', duration: 'If ECG changes', monitoring: 'ECG' },
+                    { drug: 'Regular insulin', dose: '10 units IV with D50 25g', route: 'IV', frequency: 'Once', duration: 'May repeat', monitoring: 'Blood glucose' },
+                    { drug: 'Sodium polystyrene sulfonate', dose: '15-30g PO/PR', route: 'PO or PR', frequency: 'Q6h', duration: 'PRN', monitoring: 'K level' }
+                ]
+            },
+            {
+                step: 5,
+                action: 'Hyperphosphatemia management',
+                timing: 'If phosphate elevated',
+                details: 'Phosphate binders, avoid calcium if product >60',
+                medications: [{
+                        drug: 'Sevelamer or aluminum hydroxide',
+                        dose: 'Sevelamer 800-1600mg TID with meals',
+                        route: 'PO',
+                        frequency: 'TID with meals',
+                        duration: 'Until phosphate normalized',
+                        monitoring: 'Phosphate level'
+                    }]
+            }
+        ],
+        definitiveManagement: [
+            {
+                intervention: 'Hemodialysis',
+                indication: 'Refractory hyperkalemia, volume overload, severe renal failure, refractory hyperphosphatemia',
+                timing: 'Within hours if indicated',
+                expectedOutcome: 'Correction of metabolic abnormalities'
+            },
+            {
+                intervention: 'Continuous renal replacement therapy (CRRT)',
+                indication: 'Hemodynamically unstable patients',
+                timing: 'When dialysis needed but unstable',
+                expectedOutcome: 'Slower, more stable correction'
+            }
+        ],
+        monitoring: {
+            parameters: ['Potassium', 'Phosphate', 'Calcium', 'Uric acid', 'Creatinine', 'LDH', 'Urine output', 'ECG'],
+            frequency: 'Every 4-6 hours initially',
+            escalationCriteria: ['K >6.5', 'Creatinine doubling', 'Anuria', 'Arrhythmias'],
+            deescalationCriteria: ['Normalizing labs', 'Stable renal function', 'Adequate urine output']
+        },
+        outcomes: {
+            withTreatment: 'Mortality 5-10% with aggressive management',
+            withoutTreatment: 'Mortality up to 50% with renal failure',
+            longTermPrognosis: 'Renal function usually recovers; prognosis depends on underlying cancer'
+        },
+        preventionStrategies: [
+            'Risk stratification before treatment',
+            'Prophylactic hydration and hypouricemic therapy',
+            'Avoid nephrotoxins',
+            'Close lab monitoring during treatment'
+        ]
+    },
+    {
+        id: 'hypercalcemia-malignancy',
+        name: 'Hypercalcemia of Malignancy',
+        category: 'Metabolic',
+        urgency: 'Urgent',
+        timeToIntervention: 'Within 24 hours',
+        recognition: {
+            symptoms: [
+                'Fatigue and weakness',
+                'Confusion, altered mental status',
+                'Nausea/vomiting, anorexia',
+                'Constipation',
+                'Polyuria/polydipsia',
+                'Bone pain',
+                'Abdominal pain'
+            ],
+            signs: [
+                'Dehydration',
+                'Bradycardia or arrhythmias',
+                'Hyporeflexia',
+                'Shortened QT interval on ECG'
+            ],
+            diagnosticCriteria: [
+                'Corrected calcium >10.5 mg/dL (or ionized >5.6 mg/dL)',
+                'Mild: 10.5-12 mg/dL',
+                'Moderate: 12-14 mg/dL',
+                'Severe: >14 mg/dL or symptomatic'
+            ],
+            labFindings: [
+                'Elevated corrected calcium or ionized calcium',
+                'Low or suppressed PTH (if humoral)',
+                'Elevated PTHrP (humoral hypercalcemia)',
+                'Elevated 1,25-dihydroxyvitamin D (lymphoma)',
+                'May have elevated creatinine (dehydration)'
+            ],
+            riskFactors: [
+                'Squamous cell carcinomas (lung, H&N)',
+                'Breast cancer',
+                'Renal cell carcinoma',
+                'Multiple myeloma',
+                'Lymphoma (1,25-D mediated)',
+                'Bone metastases'
+            ]
+        },
+        initialManagement: [
+            {
+                step: 1,
+                action: 'Aggressive IV hydration',
+                timing: 'Immediately',
+                details: 'NS 200-500 mL/hr initially, adjust based on cardiac status',
+                medications: [{
+                        drug: 'Normal saline',
+                        dose: '200-500 mL/hr initially (4-6L in first 24h)',
+                        route: 'IV',
+                        frequency: 'Continuous',
+                        duration: 'Until euvolemic and calcium improving',
+                        monitoring: 'I/Os, weight, cardiac status, electrolytes'
+                    }]
+            },
+            {
+                step: 2,
+                action: 'Bisphosphonate therapy',
+                timing: 'After rehydration initiated',
+                details: 'Zoledronic acid preferred; onset 2-4 days, peak 4-7 days',
+                medications: [{
+                        drug: 'Zoledronic acid',
+                        dose: '4 mg IV over 15-30 min',
+                        route: 'IV',
+                        frequency: 'Once (may repeat after 7 days)',
+                        duration: 'Single dose',
+                        monitoring: 'Renal function, calcium, jaw pain'
+                    }]
+            },
+            {
+                step: 3,
+                action: 'Denosumab (if bisphosphonate-refractory or renal impairment)',
+                timing: 'Alternative to bisphosphonate',
+                details: 'Can use in renal insufficiency',
+                medications: [{
+                        drug: 'Denosumab',
+                        dose: '120 mg SC',
+                        route: 'SC',
+                        frequency: 'Weekly x 4, then monthly',
+                        duration: 'Ongoing',
+                        monitoring: 'Calcium (risk of severe hypocalcemia)'
+                    }]
+            },
+            {
+                step: 4,
+                action: 'Calcitonin (for rapid but temporary effect)',
+                timing: 'If severe hypercalcemia requiring rapid reduction',
+                details: 'Works within 4-6 hours but tachyphylaxis in 48-72h',
+                medications: [{
+                        drug: 'Calcitonin salmon',
+                        dose: '4-8 IU/kg SC or IM q12h',
+                        route: 'SC or IM',
+                        frequency: 'Every 12 hours',
+                        duration: 'Max 48-72 hours (tachyphylaxis)',
+                        monitoring: 'Calcium, allergic reaction'
+                    }]
+            },
+            {
+                step: 5,
+                action: 'Corticosteroids (if 1,25-D mediated)',
+                timing: 'For lymphoma or myeloma',
+                details: 'Reduces 1,25-dihydroxyvitamin D production',
+                medications: [{
+                        drug: 'Prednisone or hydrocortisone',
+                        dose: 'Prednisone 20-40mg PO daily or hydrocortisone 100-300mg IV daily',
+                        route: 'PO or IV',
+                        frequency: 'Daily or divided',
+                        duration: 'Until calcium controlled',
+                        monitoring: 'Blood glucose'
+                    }]
+            }
+        ],
+        definitiveManagement: [
+            {
+                intervention: 'Treat underlying malignancy',
+                indication: 'All patients',
+                timing: 'As soon as stabilized',
+                expectedOutcome: 'Long-term calcium control'
+            },
+            {
+                intervention: 'Hemodialysis',
+                indication: 'Severe refractory hypercalcemia or renal failure',
+                timing: 'When other measures fail',
+                expectedOutcome: 'Rapid calcium reduction'
+            }
+        ],
+        monitoring: {
+            parameters: ['Calcium (corrected or ionized)', 'Creatinine', 'Magnesium', 'Phosphate', 'ECG', 'I/Os'],
+            frequency: 'Every 6-12 hours initially',
+            escalationCriteria: ['Calcium not improving after 24-48h', 'New arrhythmias', 'Worsening mental status'],
+            deescalationCriteria: ['Calcium <12', 'Symptoms resolving', 'Stable renal function']
+        },
+        outcomes: {
+            withTreatment: 'Calcium normalizes in 70-80% within 4-7 days',
+            withoutTreatment: 'Progressive encephalopathy, renal failure, cardiac arrhythmias, death',
+            longTermPrognosis: 'Often recurs without cancer treatment; median survival 30-90 days'
+        },
+        preventionStrategies: [
+            'Regular calcium monitoring in at-risk cancers',
+            'Adequate hydration',
+            'Bone-targeted agents for bone metastases',
+            'Effective cancer treatment'
+        ]
+    },
+    {
+        id: 'siadh',
+        name: 'SIADH (Syndrome of Inappropriate ADH)',
+        category: 'Metabolic',
+        urgency: 'Urgent',
+        timeToIntervention: 'Within 24 hours',
+        recognition: {
+            symptoms: [
+                'Nausea/vomiting',
+                'Headache',
+                'Confusion',
+                'Lethargy',
+                'Muscle cramps',
+                'Seizures (if severe)'
+            ],
+            signs: [
+                'Euvolemic or mildly hypervolemic',
+                'No edema, no JVD',
+                'Decreased reflexes',
+                'Altered mental status'
+            ],
+            diagnosticCriteria: [
+                'Serum Na <135 mEq/L',
+                'Serum osmolality <275 mOsm/kg',
+                'Urine osmolality >100 mOsm/kg (inappropriately concentrated)',
+                'Urine sodium >30 mEq/L',
+                'Euvolemic state',
+                'Normal thyroid and adrenal function'
+            ],
+            labFindings: [
+                'Hyponatremia',
+                'Low serum osmolality',
+                'Urine osmolality > serum osmolality',
+                'Elevated urine sodium',
+                'Low uric acid'
+            ],
+            riskFactors: [
+                'Small cell lung cancer (most common)',
+                'Head and neck cancers',
+                'CNS tumors/metastases',
+                'Certain chemotherapies (vincristine, cyclophosphamide, ifosfamide, melphalan)'
+            ]
+        },
+        initialManagement: [
+            {
+                step: 1,
+                action: 'Assess severity and symptoms',
+                timing: 'Immediately',
+                details: 'Severe: Na <120 or symptomatic; Moderate: 120-125; Mild: 125-134'
+            },
+            {
+                step: 2,
+                action: 'Fluid restriction (mild-moderate, asymptomatic)',
+                timing: 'Immediately',
+                details: 'Restrict to 800-1000 mL/day',
+                medications: [{
+                        drug: 'Fluid restriction',
+                        dose: '800-1000 mL/day total intake',
+                        route: 'PO/IV',
+                        frequency: 'Daily',
+                        duration: 'Until sodium normalized',
+                        monitoring: 'Daily sodium, I/Os'
+                    }]
+            },
+            {
+                step: 3,
+                action: 'Hypertonic saline (severe or symptomatic)',
+                timing: 'If Na <120 or symptomatic',
+                details: 'Goal: raise Na 4-6 mEq/L in first 6 hours, max 8-10 in 24h',
+                medications: [{
+                        drug: '3% NaCl',
+                        dose: '1-2 mL/kg/hr (or 100mL bolus if seizing)',
+                        route: 'IV',
+                        frequency: 'Continuous',
+                        duration: 'Until Na increases 4-6 mEq/L',
+                        monitoring: 'Sodium q2h, watch for overcorrection'
+                    }]
+            },
+            {
+                step: 4,
+                action: 'Demeclocycline or tolvaptan (chronic/refractory)',
+                timing: 'For chronic SIADH',
+                details: 'Tolvaptan requires inpatient initiation',
+                medications: [{
+                        drug: 'Tolvaptan',
+                        dose: '15 mg PO daily, titrate to 60mg max',
+                        route: 'PO',
+                        frequency: 'Daily',
+                        duration: 'Ongoing',
+                        monitoring: 'Sodium q6h first 24h, then daily; hepatic function'
+                    }],
+                contraindications: ['Hypovolemia', 'Unable to sense thirst', 'Liver disease']
+            }
+        ],
+        definitiveManagement: [
+            {
+                intervention: 'Treat underlying malignancy',
+                indication: 'All patients',
+                timing: 'As soon as possible',
+                expectedOutcome: 'Resolution of SIADH if tumor responds'
+            }
+        ],
+        monitoring: {
+            parameters: ['Serum sodium', 'Urine sodium', 'Serum and urine osmolality', 'Mental status'],
+            frequency: 'Every 4-6 hours during active treatment',
+            escalationCriteria: ['Sodium falling despite treatment', 'Seizures', 'Overcorrection risk'],
+            deescalationCriteria: ['Sodium normalizing', 'Symptoms resolved']
+        },
+        outcomes: {
+            withTreatment: 'Sodium corrects in most patients',
+            withoutTreatment: 'Cerebral edema, seizures, death if severe',
+            longTermPrognosis: 'May recur without cancer treatment'
+        },
+        preventionStrategies: [
+            'Monitor sodium in high-risk cancers',
+            'Educate patients about symptoms',
+            'Avoid excessive fluid intake'
+        ]
+    }
+];
+// ═══════════════════════════════════════════════════════════════════════════════
+// TREATMENT-RELATED EMERGENCIES
+// ═══════════════════════════════════════════════════════════════════════════════
+export const TREATMENT_RELATED_EMERGENCIES = [
+    {
+        id: 'febrile-neutropenia',
+        name: 'Febrile Neutropenia',
+        category: 'Infectious',
+        urgency: 'Immediate',
+        timeToIntervention: 'Within 1 hour',
+        recognition: {
+            symptoms: [
+                'Fever (often only sign)',
+                'Chills/rigors',
+                'May lack typical infection symptoms due to neutropenia'
+            ],
+            signs: [
+                'Temperature ≥38.3°C (101°F) single or ≥38.0°C (100.4°F) sustained >1 hour',
+                'Hypotension if septic',
+                'Tachycardia',
+                'May lack localized findings'
+            ],
+            diagnosticCriteria: [
+                'Fever ≥38.3°C single or ≥38.0°C sustained',
+                'ANC <500/µL or <1000/µL with expected decline to <500'
+            ],
+            labFindings: [
+                'ANC <500/µL (or <1000 expected to fall)',
+                'May have elevated lactate if septic',
+                'Blood cultures pending'
+            ],
+            riskFactors: [
+                'Recent myelosuppressive chemotherapy (7-14 days prior)',
+                'Hematologic malignancy',
+                'Prolonged neutropenia expected',
+                'Mucositis',
+                'Indwelling catheter'
+            ]
+        },
+        initialManagement: [
+            {
+                step: 1,
+                action: 'Risk stratification (MASCC score)',
+                timing: 'Immediately',
+                details: 'MASCC ≥21 = low risk, <21 = high risk; determines inpatient vs outpatient'
+            },
+            {
+                step: 2,
+                action: 'Blood cultures and workup',
+                timing: 'Before antibiotics but do not delay abx',
+                details: '2 sets of cultures (if central line, one from line); UA, CXR if indicated'
+            },
+            {
+                step: 3,
+                action: 'Empiric broad-spectrum antibiotics',
+                timing: 'Within 1 hour of presentation',
+                details: 'Monotherapy with anti-pseudomonal beta-lactam',
+                medications: [{
+                        drug: 'Cefepime OR Piperacillin-tazobactam OR Meropenem',
+                        dose: 'Cefepime 2g IV q8h OR Pip-tazo 4.5g IV q6h OR Meropenem 1g IV q8h',
+                        route: 'IV',
+                        frequency: 'Every 6-8 hours',
+                        duration: 'Until ANC recovery and afebrile ≥48h',
+                        monitoring: 'Temp, cultures, ANC'
+                    }]
+            },
+            {
+                step: 4,
+                action: 'Add vancomycin if indicated',
+                timing: 'If hemodynamically unstable, line infection suspected, skin/soft tissue infection, MRSA colonized, or PNA',
+                details: 'Not routine in all FN',
+                medications: [{
+                        drug: 'Vancomycin',
+                        dose: '15-20 mg/kg IV q8-12h',
+                        route: 'IV',
+                        frequency: 'Every 8-12 hours',
+                        duration: 'Until cultures negative x 48h or source ruled out',
+                        monitoring: 'Trough levels, creatinine'
+                    }]
+            },
+            {
+                step: 5,
+                action: 'Add antifungal if persistent fever',
+                timing: 'After 4-7 days of persistent fever despite antibiotics',
+                details: 'Especially if high-risk (prolonged neutropenia, heme malignancy)',
+                medications: [{
+                        drug: 'Caspofungin OR Voriconazole OR Liposomal amphotericin',
+                        dose: 'Caspofungin 70mg day 1 then 50mg daily',
+                        route: 'IV',
+                        frequency: 'Daily',
+                        duration: 'Until ANC recovery',
+                        monitoring: 'LFTs, galactomannan/beta-glucan'
+                    }]
+            },
+            {
+                step: 6,
+                action: 'G-CSF consideration',
+                timing: 'Not routine, consider if high risk for complications',
+                details: 'Consider if expected prolonged neutropenia, pneumonia, sepsis, fungal infection',
+                medications: [{
+                        drug: 'Filgrastim or pegfilgrastim',
+                        dose: 'Filgrastim 5 mcg/kg SC daily',
+                        route: 'SC',
+                        frequency: 'Daily until ANC recovery',
+                        duration: 'Until ANC >1000-1500',
+                        monitoring: 'ANC, bone pain'
+                    }]
+            }
+        ],
+        definitiveManagement: [
+            {
+                intervention: 'Outpatient management (low risk)',
+                indication: 'MASCC ≥21, stable, able to take PO, close follow-up available',
+                timing: 'After initial evaluation',
+                expectedOutcome: 'Safe in appropriately selected patients',
+                alternatives: ['Admit if any concern']
+            },
+            {
+                intervention: 'Inpatient IV antibiotics (high risk)',
+                indication: 'MASCC <21 or any concerning features',
+                timing: 'Admission',
+                expectedOutcome: 'Close monitoring and treatment'
+            }
+        ],
+        monitoring: {
+            parameters: ['Temperature', 'Vital signs', 'ANC', 'Cultures', 'Symptom assessment'],
+            frequency: 'Q4h vitals, daily labs',
+            escalationCriteria: ['Persistent fever >72h', 'Hemodynamic instability', 'New organ dysfunction', 'Clinical deterioration'],
+            deescalationCriteria: ['Afebrile ≥48h', 'ANC recovering', 'Cultures negative', 'Clinically stable']
+        },
+        outcomes: {
+            withTreatment: 'Mortality 5-10% overall (higher in high-risk)',
+            withoutTreatment: 'Sepsis and death within hours',
+            longTermPrognosis: 'Usually recovers; may delay further chemotherapy'
+        },
+        preventionStrategies: [
+            'G-CSF prophylaxis for high-risk regimens',
+            'Antimicrobial prophylaxis (fluoroquinolone) for high-risk',
+            'Dose reductions if prior FN',
+            'Patient education on fever reporting'
+        ]
+    },
+    {
+        id: 'cytokine-release-syndrome',
+        name: 'Cytokine Release Syndrome (CRS)',
+        category: 'Treatment-Related',
+        urgency: 'Immediate',
+        timeToIntervention: 'Within hours',
+        recognition: {
+            symptoms: [
+                'Fever (hallmark)',
+                'Fatigue',
+                'Myalgias',
+                'Nausea',
+                'Headache',
+                'Dyspnea'
+            ],
+            signs: [
+                'Hypotension',
+                'Tachycardia',
+                'Hypoxia',
+                'Capillary leak (edema)',
+                'Coagulopathy',
+                'Organ dysfunction'
+            ],
+            diagnosticCriteria: [
+                'ASTCT Grading:',
+                'Grade 1: Fever ≥38°C',
+                'Grade 2: Fever + hypotension not requiring pressors AND/OR hypoxia requiring low-flow O2',
+                'Grade 3: Fever + hypotension requiring a pressor (with or without vasopressin) AND/OR hypoxia requiring high-flow O2 or non-invasive ventilation',
+                'Grade 4: Fever + hypotension requiring multiple pressors AND/OR hypoxia requiring positive pressure ventilation'
+            ],
+            labFindings: [
+                'Elevated CRP (early marker)',
+                'Elevated ferritin',
+                'Elevated IL-6',
+                'Coagulopathy (elevated D-dimer, hypofibrinogenemia)',
+                'Cytopenias',
+                'Elevated LFTs',
+                'Elevated creatinine'
+            ],
+            riskFactors: [
+                'CAR-T cell therapy (most common)',
+                'Bispecific T-cell engagers (blinatumomab, teclistamab)',
+                'High tumor burden',
+                'High CAR-T dose',
+                'Early onset post-infusion'
+            ]
+        },
+        initialManagement: [
+            {
+                step: 1,
+                action: 'Supportive care (Grade 1)',
+                timing: 'Immediately',
+                details: 'Antipyretics, IVF, monitoring',
+                medications: [{
+                        drug: 'Acetaminophen',
+                        dose: '650-1000 mg PO/IV q4-6h PRN',
+                        route: 'PO or IV',
+                        frequency: 'Every 4-6 hours as needed',
+                        duration: 'While febrile',
+                        monitoring: 'Temperature, LFTs'
+                    }]
+            },
+            {
+                step: 2,
+                action: 'Tocilizumab (Grade 2+)',
+                timing: 'At grade 2 CRS',
+                details: 'IL-6 receptor antagonist; may use earlier in high-risk',
+                medications: [{
+                        drug: 'Tocilizumab',
+                        dose: '8 mg/kg IV (max 800mg)',
+                        route: 'IV over 1 hour',
+                        frequency: 'May repeat q8h (max 4 doses)',
+                        duration: 'Until CRS resolving',
+                        monitoring: 'Response, LFTs, platelets'
+                    }]
+            },
+            {
+                step: 3,
+                action: 'Corticosteroids (refractory or Grade 3+)',
+                timing: 'If no response to tocilizumab or Grade 3-4',
+                details: 'May affect CAR-T efficacy; use judiciously',
+                medications: [{
+                        drug: 'Dexamethasone',
+                        dose: '10 mg IV q6-12h (or methylprednisolone 1-2 mg/kg)',
+                        route: 'IV',
+                        frequency: 'Every 6-12 hours',
+                        duration: 'Taper over days as CRS improves',
+                        monitoring: 'Blood glucose, infection signs'
+                    }]
+            },
+            {
+                step: 4,
+                action: 'Vasopressor support (Grade 3-4)',
+                timing: 'If hypotension not responsive to fluids',
+                details: 'ICU level care required'
+            },
+            {
+                step: 5,
+                action: 'Siltuximab (tocilizumab-refractory)',
+                timing: 'If CRS refractory to tocilizumab',
+                details: 'Direct IL-6 antibody',
+                medications: [{
+                        drug: 'Siltuximab',
+                        dose: '11 mg/kg IV',
+                        route: 'IV over 1 hour',
+                        frequency: 'Single dose',
+                        duration: 'Once',
+                        monitoring: 'Response'
+                    }]
+            }
+        ],
+        definitiveManagement: [
+            {
+                intervention: 'ICU admission',
+                indication: 'Grade 3-4 CRS',
+                timing: 'Immediately',
+                expectedOutcome: 'Close monitoring and organ support'
+            },
+            {
+                intervention: 'Anakinra (IL-1 blockade)',
+                indication: 'Refractory to tocilizumab and steroids',
+                timing: 'For refractory cases',
+                expectedOutcome: 'May help in steroid-refractory cases'
+            }
+        ],
+        monitoring: {
+            parameters: ['Temperature', 'BP', 'O2 saturation', 'CRP', 'Ferritin', 'IL-6', 'Organ function'],
+            frequency: 'Q4h vitals, daily labs (more frequent if unstable)',
+            escalationCriteria: ['Increasing grade', 'New organ dysfunction', 'Refractory to tocilizumab'],
+            deescalationCriteria: ['Resolution of fever', 'Stable hemodynamics off pressors', 'Improving CRP']
+        },
+        outcomes: {
+            withTreatment: 'Mortality <5% with modern management',
+            withoutTreatment: 'Multi-organ failure and death',
+            longTermPrognosis: 'CRS itself doesn\'t affect long-term outcomes if well-managed'
+        },
+        preventionStrategies: [
+            'Pre-treatment with steroids or tocilizumab (prophylactic) in some settings',
+            'Lower CAR-T doses in high tumor burden',
+            'Debulking chemotherapy before CAR-T',
+            'Close monitoring in first 10 days'
+        ]
+    },
+    {
+        id: 'immune-checkpoint-irae',
+        name: 'Immune-Related Adverse Events (irAEs)',
+        category: 'Treatment-Related',
+        urgency: 'Urgent',
+        timeToIntervention: 'Within 24-48 hours (immediate for severe)',
+        recognition: {
+            symptoms: [
+                'Vary by organ system affected',
+                'Diarrhea (colitis)',
+                'Dyspnea, cough (pneumonitis)',
+                'Fatigue (endocrinopathy)',
+                'Rash',
+                'Hepatic symptoms (jaundice, RUQ pain)',
+                'Neurologic symptoms'
+            ],
+            signs: [
+                'Skin: maculopapular rash, vitiligo',
+                'GI: abdominal tenderness, bloody stool',
+                'Pulmonary: crackles, hypoxia',
+                'Hepatic: jaundice, hepatomegaly',
+                'Endocrine: hypotension (adrenal), bradycardia (thyroid)'
+            ],
+            diagnosticCriteria: [
+                'Temporal relationship to ICI therapy',
+                'Exclusion of other causes (infection, progression)',
+                'CTCAE grading:',
+                'Grade 1: Mild',
+                'Grade 2: Moderate',
+                'Grade 3: Severe',
+                'Grade 4: Life-threatening'
+            ],
+            labFindings: [
+                'Colitis: Fecal calprotectin elevated',
+                'Hepatitis: Elevated AST/ALT, bilirubin',
+                'Pneumonitis: Hypoxia on ABG',
+                'Thyroiditis: TSH, free T4 abnormal',
+                'Hypophysitis: Low ACTH, cortisol, TSH'
+            ],
+            riskFactors: [
+                'Combination ICI (anti-PD1 + anti-CTLA4)',
+                'Prior autoimmune disease',
+                'High tumor burden',
+                'Certain tumor types'
+            ]
+        },
+        initialManagement: [
+            {
+                step: 1,
+                action: 'Grade assessment and ICI hold',
+                timing: 'Immediately',
+                details: 'Hold ICI for Grade 2+ (may continue for Grade 1 with monitoring)'
+            },
+            {
+                step: 2,
+                action: 'Corticosteroids for Grade 2+ irAEs',
+                timing: 'Immediately',
+                details: 'Prednisone 0.5-1 mg/kg for Grade 2, 1-2 mg/kg for Grade 3+',
+                medications: [{
+                        drug: 'Prednisone (or IV methylprednisolone if severe)',
+                        dose: 'Grade 2: 0.5-1 mg/kg/day; Grade 3-4: 1-2 mg/kg/day (max 80-120mg)',
+                        route: 'PO (or IV if unable to take PO)',
+                        frequency: 'Once daily (or divided BID)',
+                        duration: 'Taper over 4-6 weeks after improvement',
+                        monitoring: 'Symptom improvement, glucose, infection'
+                    }]
+            },
+            {
+                step: 3,
+                action: 'Add immunosuppression for refractory cases',
+                timing: 'If no improvement in 48-72 hours on high-dose steroids',
+                details: 'Organ-specific agents: infliximab for colitis, MMF for hepatitis, etc.',
+                medications: [{
+                        drug: 'Infliximab (for colitis)',
+                        dose: '5 mg/kg IV',
+                        route: 'IV',
+                        frequency: 'Single dose (may repeat in 2 weeks)',
+                        duration: '1-2 doses usually',
+                        monitoring: 'Response, TB screen prior'
+                    }]
+            },
+            {
+                step: 4,
+                action: 'Specialty consultation',
+                timing: 'For Grade 3+ or uncertain diagnosis',
+                details: 'GI for colitis, pulmonary for pneumonitis, endocrine for endocrinopathies'
+            }
+        ],
+        definitiveManagement: [
+            {
+                intervention: 'Permanent ICI discontinuation',
+                indication: 'Grade 4 irAE (most), Grade 3 that recurs, myocarditis, encephalitis',
+                timing: 'After recovery',
+                expectedOutcome: 'Prevents recurrence'
+            },
+            {
+                intervention: 'ICI rechallenge consideration',
+                indication: 'Recovered Grade 2-3 after discussion of risks',
+                timing: 'After complete resolution',
+                expectedOutcome: '30-50% may have recurrent irAE; many tolerate rechallenge'
+            },
+            {
+                intervention: 'Hormone replacement',
+                indication: 'Permanent endocrine irAEs (thyroid, adrenal, pituitary)',
+                timing: 'Ongoing',
+                expectedOutcome: 'Lifelong replacement usually needed'
+            }
+        ],
+        monitoring: {
+            parameters: ['Symptoms', 'Relevant labs (LFTs, TFTs, cortisol)', 'Imaging if indicated'],
+            frequency: 'Daily during acute management, weekly during taper',
+            escalationCriteria: ['No improvement in 48-72h', 'Worsening grade', 'New organ involvement'],
+            deescalationCriteria: ['Symptoms improving', 'Labs normalizing', 'Tolerating steroid taper']
+        },
+        outcomes: {
+            withTreatment: 'Most Grade 1-3 irAEs resolve with steroids',
+            withoutTreatment: 'Organ damage, potentially fatal (especially myocarditis, pneumonitis)',
+            longTermPrognosis: 'May have permanent endocrine deficiencies; some irAEs predict better tumor response'
+        },
+        preventionStrategies: [
+            'Patient education on irAE recognition',
+            'Close monitoring during therapy',
+            'Avoid ICIs in active severe autoimmune disease',
+            'Lower threshold for steroids in elderly/frail'
+        ]
+    },
+    {
+        id: 'extravasation',
+        name: 'Chemotherapy Extravasation',
+        category: 'Treatment-Related',
+        urgency: 'Immediate',
+        timeToIntervention: 'Within minutes',
+        recognition: {
+            symptoms: [
+                'Pain or burning at IV site (may be absent with vesicants)',
+                'Swelling',
+                'Redness'
+            ],
+            signs: [
+                'Swelling at infusion site',
+                'Blanching or erythema',
+                'Induration',
+                'Blistering (late)',
+                'Tissue necrosis (late)'
+            ],
+            diagnosticCriteria: [
+                'Suspect if: pain, swelling, or resistance during infusion',
+                'Lack of blood return (may not be reliable)',
+                'Infiltration outside vein on imaging (if done)'
+            ],
+            riskFactors: [
+                'Vesicant agents (doxorubicin, vincristine, vinorelbine, mechlorethamine)',
+                'Peripheral IV access',
+                'Small fragile veins',
+                'Multiple prior IVs',
+                'Elderly patients'
+            ]
+        },
+        initialManagement: [
+            {
+                step: 1,
+                action: 'Stop infusion immediately',
+                timing: 'Immediately',
+                details: 'Leave catheter in place initially'
+            },
+            {
+                step: 2,
+                action: 'Aspirate residual drug',
+                timing: 'Immediately',
+                details: 'Attempt to aspirate extravasated drug through catheter'
+            },
+            {
+                step: 3,
+                action: 'Remove catheter and mark area',
+                timing: 'After aspiration attempt',
+                details: 'Outline extravasation area with marker'
+            },
+            {
+                step: 4,
+                action: 'Apply appropriate antidote (drug-specific)',
+                timing: 'Within 10-15 minutes',
+                details: 'See specific antidotes below'
+            },
+            {
+                step: 5,
+                action: 'Anthracycline (doxorubicin, epirubicin) - Dexrazoxane',
+                timing: 'Within 6 hours, ideally ASAP',
+                details: 'Three day regimen',
+                medications: [{
+                        drug: 'Dexrazoxane',
+                        dose: 'Day 1-2: 1000 mg/m² IV; Day 3: 500 mg/m² IV (max 2000mg per dose)',
+                        route: 'IV over 1-2 hours',
+                        frequency: 'Daily x 3 days',
+                        duration: '3 days',
+                        monitoring: 'Start within 6h; may cause myelosuppression'
+                    }]
+            },
+            {
+                step: 6,
+                action: 'Vinca alkaloids (vincristine, vinblastine) - Heat + Hyaluronidase',
+                timing: 'Within 1 hour',
+                details: 'Heat disperses drug; hyaluronidase aids spread for dilution',
+                medications: [{
+                        drug: 'Hyaluronidase',
+                        dose: '150-900 units SC around site',
+                        route: 'SC (multiple injections around site)',
+                        frequency: 'Once',
+                        duration: 'Single treatment',
+                        monitoring: 'Apply dry warm compresses for 24-48h'
+                    }]
+            },
+            {
+                step: 7,
+                action: 'Taxanes (paclitaxel, docetaxel) - Cold compresses',
+                timing: 'Immediately',
+                details: 'Apply cold compresses for 15-20 min QID x 24-48h'
+            },
+            {
+                step: 8,
+                action: 'Platinum compounds (cisplatin) - No specific antidote',
+                timing: 'Supportive',
+                details: 'Cold compresses, elevation; usually less severe'
+            }
+        ],
+        definitiveManagement: [
+            {
+                intervention: 'Plastic surgery consultation',
+                indication: 'Progressive tissue damage, suspected deep necrosis',
+                timing: 'Within 24-72 hours if not improving',
+                expectedOutcome: 'May need debridement and reconstruction'
+            },
+            {
+                intervention: 'Serial photography and documentation',
+                indication: 'All extravasations',
+                timing: 'Daily for first week',
+                expectedOutcome: 'Documentation for monitoring and medicolegal'
+            }
+        ],
+        monitoring: {
+            parameters: ['Pain', 'Erythema', 'Swelling', 'Blistering', 'Skin integrity'],
+            frequency: 'Immediately, then q12-24h for 72h, then as needed',
+            escalationCriteria: ['Progressive tissue damage', 'Blistering', 'Skin breakdown', 'Severe pain'],
+            deescalationCriteria: ['Improving pain and swelling', 'No skin changes']
+        },
+        outcomes: {
+            withTreatment: 'Most heal without sequelae if treated promptly',
+            withoutTreatment: 'Deep tissue necrosis, need for skin grafting, permanent injury',
+            longTermPrognosis: 'Dependent on prompt recognition and treatment'
+        },
+        preventionStrategies: [
+            'Central venous access for vesicants',
+            'Careful IV placement and monitoring',
+            'Slow test infusion before full rate',
+            'Patient education on reporting symptoms',
+            'Trained oncology nursing staff'
+        ]
+    }
+];
+// ═══════════════════════════════════════════════════════════════════════════════
+// HEMATOLOGIC EMERGENCIES
+// ═══════════════════════════════════════════════════════════════════════════════
+export const HEMATOLOGIC_EMERGENCIES = [
+    {
+        id: 'leukostasis',
+        name: 'Leukostasis (Hyperleukocytosis)',
+        category: 'Hematologic',
+        urgency: 'Immediate',
+        timeToIntervention: 'Within hours',
+        recognition: {
+            symptoms: [
+                'Dyspnea, respiratory distress',
+                'Confusion, headache, visual changes',
+                'Priapism (rarely)'
+            ],
+            signs: [
+                'Hypoxia',
+                'Altered mental status',
+                'Retinal hemorrhages',
+                'Pulmonary infiltrates',
+                'DIC signs'
+            ],
+            diagnosticCriteria: [
+                'WBC >100,000/µL (AML) or >200-300,000/µL (ALL)',
+                'Symptoms of pulmonary or CNS leukostasis'
+            ],
+            labFindings: [
+                'Markedly elevated WBC',
+                'May have spurious hyperkalemia, hypoglycemia (pseudohyperkalemia)',
+                'Elevated LDH, uric acid',
+                'DIC parameters often abnormal'
+            ],
+            riskFactors: [
+                'Acute myeloid leukemia (monocytic subtypes M4, M5)',
+                'Acute lymphoblastic leukemia (less common)',
+                'CML blast crisis',
+                'Very high WBC'
+            ]
+        },
+        initialManagement: [
+            {
+                step: 1,
+                action: 'Supportive care',
+                timing: 'Immediately',
+                details: 'O2 supplementation, avoid transfusion (increases viscosity)'
+            },
+            {
+                step: 2,
+                action: 'Hydration and TLS prophylaxis',
+                timing: 'Immediately',
+                details: 'Aggressive IVF, allopurinol or rasburicase'
+            },
+            {
+                step: 3,
+                action: 'Leukapheresis',
+                timing: 'Within hours if symptomatic',
+                details: 'Rapid reduction of WBC; bridge to chemotherapy',
+                medications: [{
+                        drug: 'Leukapheresis',
+                        dose: '1-2 blood volumes processed',
+                        route: 'Apheresis',
+                        frequency: 'Daily until WBC <50-100K',
+                        duration: '1-3 days',
+                        monitoring: 'CBC, electrolytes, coagulation'
+                    }]
+            },
+            {
+                step: 4,
+                action: 'Hydroxyurea',
+                timing: 'Immediately if leukapheresis not available',
+                details: 'Rapidly reduces WBC but less effective than leukemia-directed therapy',
+                medications: [{
+                        drug: 'Hydroxyurea',
+                        dose: '50-100 mg/kg/day in divided doses',
+                        route: 'PO',
+                        frequency: 'Divided BID-TID',
+                        duration: 'Until WBC controlled',
+                        monitoring: 'CBC daily'
+                    }]
+            },
+            {
+                step: 5,
+                action: 'Induction chemotherapy',
+                timing: 'As soon as possible',
+                details: 'Definitive treatment; start after stabilization'
+            }
+        ],
+        definitiveManagement: [
+            {
+                intervention: 'Leukemia-directed induction chemotherapy',
+                indication: 'All patients once stable',
+                timing: 'Within 24-48 hours',
+                expectedOutcome: 'Definitive WBC reduction'
+            }
+        ],
+        monitoring: {
+            parameters: ['WBC', 'O2 sat', 'Neurologic status', 'Coagulation', 'Uric acid, K, Cr'],
+            frequency: 'Every 4-6 hours initially',
+            escalationCriteria: ['Worsening hypoxia', 'Neurologic deterioration', 'DIC', 'TLS'],
+            deescalationCriteria: ['WBC declining', 'Symptoms improving', 'Stable oxygenation']
+        },
+        outcomes: {
+            withTreatment: 'Early mortality 20-40% despite treatment',
+            withoutTreatment: 'Rapid deterioration and death',
+            longTermPrognosis: 'High early mortality; survivors treated as standard AML/ALL'
+        },
+        preventionStrategies: [
+            'Early recognition and treatment of acute leukemia',
+            'Avoid unnecessary delays in starting induction'
+        ]
+    },
+    {
+        id: 'dic',
+        name: 'Disseminated Intravascular Coagulation (DIC)',
+        category: 'Hematologic',
+        urgency: 'Immediate',
+        timeToIntervention: 'Within hours',
+        recognition: {
+            symptoms: [
+                'Bleeding from multiple sites',
+                'Bruising',
+                'Petechiae',
+                'Organ dysfunction symptoms'
+            ],
+            signs: [
+                'Oozing from lines and wounds',
+                'Mucosal bleeding',
+                'Purpura fulminans (in severe cases)',
+                'Thrombosis signs (paradoxical)',
+                'Altered mental status',
+                'Oliguria'
+            ],
+            diagnosticCriteria: [
+                'ISTH DIC score ≥5:',
+                'Platelet count: >100 (0), 50-100 (1), <50 (2)',
+                'D-dimer: normal (0), moderate increase (2), strong increase (3)',
+                'PT prolongation: <3s (0), 3-6s (1), >6s (2)',
+                'Fibrinogen: ≥1g/L (0), <1g/L (1)'
+            ],
+            labFindings: [
+                'Thrombocytopenia',
+                'Elevated D-dimer',
+                'Prolonged PT/aPTT',
+                'Low fibrinogen',
+                'Schistocytes on smear'
+            ],
+            riskFactors: [
+                'Acute promyelocytic leukemia (APL)',
+                'Sepsis',
+                'Solid tumor (especially adenocarcinomas)',
+                'Obstetric complications',
+                'Trauma/surgery'
+            ]
+        },
+        initialManagement: [
+            {
+                step: 1,
+                action: 'Treat underlying cause',
+                timing: 'Immediately',
+                details: 'Antibiotics for sepsis, ATRA for APL, etc.'
+            },
+            {
+                step: 2,
+                action: 'Platelet transfusion',
+                timing: 'If plt <50 with bleeding or <20 prophylactic',
+                details: 'Maintain plt >50 if bleeding, >20-30 prophylactic',
+                medications: [{
+                        drug: 'Platelet transfusion',
+                        dose: '1 apheresis unit or 6 units pooled',
+                        route: 'IV',
+                        frequency: 'As needed',
+                        duration: 'Until DIC resolving',
+                        monitoring: 'Post-transfusion platelet count'
+                    }]
+            },
+            {
+                step: 3,
+                action: 'FFP/plasma',
+                timing: 'If PT/aPTT prolonged with bleeding',
+                details: 'Replace clotting factors',
+                medications: [{
+                        drug: 'Fresh frozen plasma',
+                        dose: '15-20 mL/kg',
+                        route: 'IV',
+                        frequency: 'Every 8-12 hours as needed',
+                        duration: 'Until DIC resolving',
+                        monitoring: 'PT/aPTT after transfusion'
+                    }]
+            },
+            {
+                step: 4,
+                action: 'Cryoprecipitate',
+                timing: 'If fibrinogen <100 mg/dL',
+                details: 'Goal fibrinogen >100-150',
+                medications: [{
+                        drug: 'Cryoprecipitate',
+                        dose: '10 units (or fibrinogen concentrate 2-4g)',
+                        route: 'IV',
+                        frequency: 'As needed',
+                        duration: 'Until fibrinogen repleted',
+                        monitoring: 'Fibrinogen level'
+                    }]
+            },
+            {
+                step: 5,
+                action: 'Anticoagulation consideration',
+                timing: 'If thrombosis predominant (Trousseau syndrome)',
+                details: 'Low-dose heparin if thrombosis; contraindicated if major bleeding',
+                medications: [{
+                        drug: 'Unfractionated heparin',
+                        dose: 'Low-dose: 5-10 U/kg/hr continuous',
+                        route: 'IV',
+                        frequency: 'Continuous',
+                        duration: 'As indicated',
+                        monitoring: 'aPTT, bleeding signs'
+                    }]
+            }
+        ],
+        definitiveManagement: [
+            {
+                intervention: 'Treatment of underlying malignancy',
+                indication: 'All cancer-associated DIC',
+                timing: 'As soon as possible',
+                expectedOutcome: 'Resolution of DIC with cancer control'
+            },
+            {
+                intervention: 'Antithrombin III concentrate',
+                indication: 'Consider if AT levels low and DIC refractory',
+                timing: 'In selected cases',
+                expectedOutcome: 'May improve outcomes in sepsis-DIC'
+            }
+        ],
+        monitoring: {
+            parameters: ['CBC', 'PT/INR', 'aPTT', 'Fibrinogen', 'D-dimer', 'Clinical bleeding'],
+            frequency: 'Every 6-8 hours initially',
+            escalationCriteria: ['Worsening coagulopathy', 'Active bleeding', 'New thrombosis'],
+            deescalationCriteria: ['Improving platelet count', 'Normalizing coagulation tests', 'Bleeding stopped']
+        },
+        outcomes: {
+            withTreatment: 'Dependent on underlying cause; APL-DIC very treatable',
+            withoutTreatment: 'Massive hemorrhage or thrombosis, organ failure',
+            longTermPrognosis: 'Resolves with treatment of underlying condition'
+        },
+        preventionStrategies: [
+            'Early recognition and treatment of underlying cause',
+            'Close monitoring in high-risk cancers (APL, adenocarcinoma)'
+        ]
+    }
+];
+// ═══════════════════════════════════════════════════════════════════════════════
+// EMERGENCY ONCOLOGY ENGINE
+// ═══════════════════════════════════════════════════════════════════════════════
+export class EmergencyOncologyEngine {
+    emergencies = new Map();
+    constructor() {
+        this.initializeEmergencies();
+    }
+    initializeEmergencies() {
+        const allEmergencies = [
+            ...STRUCTURAL_EMERGENCIES,
+            ...METABOLIC_EMERGENCIES,
+            ...TREATMENT_RELATED_EMERGENCIES,
+            ...HEMATOLOGIC_EMERGENCIES
+        ];
+        for (const emergency of allEmergencies) {
+            this.emergencies.set(emergency.id, emergency);
+        }
+    }
+    getEmergency(id) {
+        return this.emergencies.get(id);
+    }
+    getEmergenciesByCategory(category) {
+        return Array.from(this.emergencies.values()).filter(e => e.category === category);
+    }
+    getEmergenciesByUrgency(urgency) {
+        return Array.from(this.emergencies.values()).filter(e => e.urgency === urgency);
+    }
+    identifyPotentialEmergency(symptoms, labValues) {
+        const matches = [];
+        for (const emergency of this.emergencies.values()) {
+            let score = 0;
+            // Match symptoms
+            for (const symptom of symptoms) {
+                if (emergency.recognition.symptoms.some(s => s.toLowerCase().includes(symptom.toLowerCase()))) {
+                    score += 2;
+                }
+                if (emergency.recognition.signs.some(s => s.toLowerCase().includes(symptom.toLowerCase()))) {
+                    score += 1;
+                }
+            }
+            // Match lab values if provided
+            if (labValues && emergency.recognition.labFindings) {
+                for (const finding of emergency.recognition.labFindings) {
+                    for (const [lab, value] of Object.entries(labValues)) {
+                        if (finding.toLowerCase().includes(lab.toLowerCase())) {
+                            score += 1;
+                        }
+                    }
+                }
+            }
+            if (score > 0) {
+                matches.push({ emergency, score });
+            }
+        }
+        return matches
+            .sort((a, b) => b.score - a.score)
+            .map(m => m.emergency);
+    }
+    generateEmergencyProtocol(emergencyId, patientFactors) {
+        const emergency = this.emergencies.get(emergencyId);
+        if (!emergency)
+            return undefined;
+        const contraindicatedSteps = [];
+        const prioritizedSteps = [];
+        for (const step of emergency.initialManagement) {
+            let contraindicated = false;
+            if (patientFactors?.allergies && step.medications) {
+                for (const med of step.medications) {
+                    if (patientFactors.allergies.some(a => med.drug.toLowerCase().includes(a.toLowerCase()))) {
+                        contraindicated = true;
+                        break;
+                    }
+                }
+            }
+            if (step.contraindications && patientFactors?.renalFunction === 'impaired') {
+                if (step.contraindications.some(c => c.toLowerCase().includes('renal') || c.toLowerCase().includes('kidney'))) {
+                    contraindicated = true;
+                }
+            }
+            if (contraindicated) {
+                contraindicatedSteps.push(step);
+            }
+            else {
+                prioritizedSteps.push(step);
+            }
+        }
+        const criticalTimepoints = [
+            `Time to intervention: ${emergency.timeToIntervention}`,
+            ...emergency.monitoring.escalationCriteria.map(c => `Escalate if: ${c}`)
+        ];
+        return {
+            emergency,
+            prioritizedSteps,
+            contraindicatedSteps,
+            criticalTimepoints
+        };
+    }
+    getAllEmergencies() {
+        return Array.from(this.emergencies.values());
+    }
+}
+// Export singleton instance
+export const emergencyOncologyEngine = new EmergencyOncologyEngine();
+//# sourceMappingURL=emergencyOncology.js.map