/**
 * 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                      ║
 * ╚═══════════════════════════════════════════════════════════════════════════════╝
 */

// ═══════════════════════════════════════════════════════════════════════════════
// EMERGENCY PROTOCOL DEFINITIONS
// ═══════════════════════════════════════════════════════════════════════════════

export interface OncologicEmergency {
  id: string;
  name: string;
  category: EmergencyCategory;
  urgency: 'Immediate' | 'Urgent' | 'Semi-urgent';
  timeToIntervention: string;
  recognition: RecognitionCriteria;
  initialManagement: EmergencyManagement[];
  definitiveManagement: DefinitiveManagement[];
  monitoring: MonitoringProtocol;
  outcomes: OutcomeExpectations;
  preventionStrategies: string[];
}

export type EmergencyCategory =
  | 'Structural'
  | 'Metabolic'
  | 'Hematologic'
  | 'Treatment-Related'
  | 'Infectious'
  | 'Neurologic'
  | 'Cardiovascular'
  | 'Respiratory';

export interface RecognitionCriteria {
  symptoms: string[];
  signs: string[];
  diagnosticCriteria: string[];
  labFindings?: string[];
  imagingFindings?: string[];
  riskFactors: string[];
}

export interface EmergencyManagement {
  step: number;
  action: string;
  timing: string;
  details: string;
  medications?: MedicationOrder[];
  contraindications?: string[];
}

export interface MedicationOrder {
  drug: string;
  dose: string;
  route: string;
  frequency: string;
  duration: string;
  monitoring?: string;
}

export interface DefinitiveManagement {
  intervention: string;
  indication: string;
  timing: string;
  expectedOutcome: string;
  alternatives?: string[];
}

export interface MonitoringProtocol {
  parameters: string[];
  frequency: string;
  escalationCriteria: string[];
  deescalationCriteria: string[];
}

export interface OutcomeExpectations {
  withTreatment: string;
  withoutTreatment: string;
  longTermPrognosis: string;
}

// ═══════════════════════════════════════════════════════════════════════════════
// STRUCTURAL EMERGENCIES
// ═══════════════════════════════════════════════════════════════════════════════

export const STRUCTURAL_EMERGENCIES: OncologicEmergency[] = [
  {
    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: OncologicEmergency[] = [
  {
    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: OncologicEmergency[] = [
  {
    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: OncologicEmergency[] = [
  {
    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 {
  private emergencies: Map<string, OncologicEmergency> = new Map();

  constructor() {
    this.initializeEmergencies();
  }

  private initializeEmergencies(): void {
    const allEmergencies = [
      ...STRUCTURAL_EMERGENCIES,
      ...METABOLIC_EMERGENCIES,
      ...TREATMENT_RELATED_EMERGENCIES,
      ...HEMATOLOGIC_EMERGENCIES
    ];

    for (const emergency of allEmergencies) {
      this.emergencies.set(emergency.id, emergency);
    }
  }

  getEmergency(id: string): OncologicEmergency | undefined {
    return this.emergencies.get(id);
  }

  getEmergenciesByCategory(category: EmergencyCategory): OncologicEmergency[] {
    return Array.from(this.emergencies.values()).filter(e => e.category === category);
  }

  getEmergenciesByUrgency(urgency: 'Immediate' | 'Urgent' | 'Semi-urgent'): OncologicEmergency[] {
    return Array.from(this.emergencies.values()).filter(e => e.urgency === urgency);
  }

  identifyPotentialEmergency(symptoms: string[], labValues?: Record<string, number>): OncologicEmergency[] {
    const matches: Array<{ emergency: OncologicEmergency; score: number }> = [];

    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: string,
    patientFactors?: { weight?: number; renalFunction?: string; allergies?: string[] }
  ): {
    emergency: OncologicEmergency;
    prioritizedSteps: EmergencyManagement[];
    contraindicatedSteps: EmergencyManagement[];
    criticalTimepoints: string[];
  } | undefined {
    const emergency = this.emergencies.get(emergencyId);
    if (!emergency) return undefined;

    const contraindicatedSteps: EmergencyManagement[] = [];
    const prioritizedSteps: EmergencyManagement[] = [];

    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(): OncologicEmergency[] {
    return Array.from(this.emergencies.values());
  }
}

// Export singleton instance
export const emergencyOncologyEngine = new EmergencyOncologyEngine();