Cookbook 367: Offline Clinical Critical Care Heat Stroke Bouchama & Core Cooling Engine

"""
Cookbook 367: Offline Clinical Critical Care Heat Stroke Bouchama & Core Cooling Engine
OpenPHR Clinical AI Working Group (https://openphr.org)
"""

import math
import numpy as np
import pandas as pd
from typing import Dict, List, Tuple, Optional
from dataclasses import dataclass

@dataclass
class HeatStrokeTelemetry:
    patient_id: str
    age_years: float = 24.0
    patient_weight_kg: float = 76.0
    # Thermometry Telemetry
    rectal_core_temperature_celsius: float = 41.6 # > 40.0 C = Severe Hyperpyrexia
    thermometer_site: str = "Rectal Thermistor" # "Rectal Thermistor", "Esophageal", "Axillary", "Tympanic", "Oral"
    ambient_wbgt_celsius: float = 32.5
    # Phenotype & Exposure
    heat_stroke_phenotype: str = "Exertional Heat Stroke (EHS)" # "Exertional Heat Stroke (EHS)", "Classic Non-Exertional Heat Stroke (CHS)"
    activity_context: str = "Marathon runner collapsed at mile 22"
    # Neurological & Mental Status
    cns_status: str = "Comatose / Severe Delirium with Combativeness" # "Normal", "Mild Confusion/Ataxia", "Severe Delirium/Agitation", "Seizures/Coma"
    has_active_seizures: bool = False
    is_shivering: bool = True # Shivering generates heat -> Requires suppression!
    # Hemodynamics
    heart_rate_bpm: float = 158.0
    mean_arterial_pressure_mmhg: float = 68.0
    # Cooling Telemetry
    active_cooling_modality: str = "Cold Water Immersion (CWI, 8-12 C with water circulation)" # "Cold Water Immersion (CWI)", "Evaporative + Convective Misting", "Ice Packs Alone"
    elapsed_cooling_minutes: float = 14.0
    initial_core_temp_celsius: float = 41.6
    current_core_temp_celsius: float = 39.4
    # Laboratory Biomarkers & Rhabdomyolysis
    serum_creatine_kinase_u_l: float = 34500.0 # Severe rhabdomyolysis (> 10,000 U/L)
    serum_potassium_meq_l: float = 5.2
    platelet_count_k_ul: float = 112.0
    inr: float = 1.45
    urine_output_ml_kg_hr: float = 0.85

@dataclass
class HeatStrokeEvaluationReport:
    patient_id: str
    bouchama_diagnostic_status: str # "CONFIRMED SEVERE HEAT STROKE (Bouchama Criteria Met)"
    phenotype_risk_tier: str
    observed_cooling_rate_c_min: float # e.g. 0.157 C/min
    cooling_rate_efficacy_tier: str # "OPTIMAL ACTIVE COOLING (>= 0.15 C/min)"
    immersion_extraction_target_c: str # "Extract at 38.6 - 38.9 C (Current: 39.4 C - Continue CWI)"
    resuscitation_and_shivering_orders: List[str]
    safety_sentinels: List[str]
    clinical_wms_acsm_directive: str

class HeatStrokeDecisionEngine:
    """
    Offline clinical engine for Bouchama heat stroke diagnostic validation,
    real-time core cooling rate computation, immersion extraction gating, and antipyretic sentinels.
    """

    def audit_thermometry_quality(self, d: HeatStrokeTelemetry) -> Tuple[bool, List[str]]:
        sentinels = []
        is_valid = True

        site = d.thermometer_site.lower()
        if "rectal" not in site and "esophageal" not in site:
            is_valid = False
            sentinels.append(f"🚨 INACCURATE THERMOMETRY SITE ({d.thermometer_site}): Axillary, oral, temporal, and tympanic devices underestimate core body temperature by 2.0 - 5.0 C due to peripheral vasoconstriction. MANDATORY INDWELLING RECTAL THERMISTOR PLACEMENT REQUIRED FOR CONTINUOUS SURVEILLANCE!")

        return is_valid, sentinels

    def validate_bouchama_criteria(self, d: HeatStrokeTelemetry) -> Tuple[bool, str]:
        has_hyperpyrexia = d.rectal_core_temperature_celsius >= 40.0
        cns_lower = d.cns_status.lower()
        has_cns = ("delirium" in cns_lower or "combat" in cns_lower or "coma" in cns_lower or 
                   "seizure" in cns_lower or "confusion" in cns_lower or "ataxia" in cns_lower)

        if has_hyperpyrexia and has_cns:
            return True, "CONFIRMED LIFE-THREATENING HEAT STROKE (Bouchama Criteria Met: Core Temp > 40.0 C + Encephalopathy)"
        elif has_hyperpyrexia:
            return False, "Severe Hyperthermia without Documented Neurocognitive Dysfunction"
        elif has_cns:
            return False, "Neurocognitive Dysfunction with Sub-Threshold Core Temperature (Evaluate for post-cooling state, sepsis, or CNS infection)"
        else:
            return False, "Heat Exhaustion / Mild Heat Illness"

    def calculate_cooling_velocity(self, d: HeatStrokeTelemetry) -> Tuple[float, str, str]:
        t0 = d.initial_core_temp_celsius
        t1 = d.current_core_temp_celsius
        mins = max(1.0, d.elapsed_cooling_minutes)

        delta_t = t0 - t1
        rate = round(delta_t / mins, 3) # deg C per minute

        if rate >= 0.15:
            tier = f"OPTIMAL ACTIVE COOLING VELOCITY ({rate:.3f} C/min >= 0.15 C/min target)"
        elif rate >= 0.10:
            tier = f"SUBOPTIMAL COOLING VELOCITY ({rate:.3f} C/min) - Agitate/circulate water and add ice!"
        else:
            tier = f"CRITICALLY INADEQUATE COOLING VELOCITY ({rate:.3f} C/min < 0.10 C/min) - Transition to Cold Water Immersion immediately!"

        # Immersion Extraction Gating (Target 38.6 - 38.9 C)
        if t1 <= 38.8:
            extract = f"🚨 EXTRACT PATIENT FROM IMMERSION NOW: Core temperature ({t1:.1f} C) has reached target window (38.6 - 38.9 C). Cease active cooling to prevent hypothermic afterdrop below 35.0 C!"
        else:
            extract = f"CONTINUE ACTIVE COOLING: Current Core Temp is {t1:.1f} C. Target extraction window is 38.6 - 38.9 C (Delta remaining: {t1 - 38.8:.1f} C)."

        return rate, tier, extract

    def generate_resuscitation_orders(self, d: HeatStrokeTelemetry) -> Tuple[List[str], List[str]]:
        orders = []
        sentinels = []

        orders.append("1. FIRST-LINE RAPID ACTIVE COOLING PROTOCOL:")
        if "cold water immersion" in d.active_cooling_modality.lower() or "cwi" in d.active_cooling_modality.lower():
            orders.append("   • COLD WATER IMMERSION (CWI): Submerge patient up to neck in cold/ice water (1-15 C); vigorously circulate/stir water to disrupt warm boundary layer.")
        else:
            orders.append("   • EVAPORATIVE + CONVECTIVE RESCUE: Continuous spraying of tepid mist (20-25 C) over entire exposed body with high-flow industrial fans.")

        # Shivering Mitigation
        if d.is_shivering:
            orders.append("2. STAT SHIVERING SUPPRESSION (To maintain high cooling velocity):")
            orders.append("   • Administer IV Midazolam 1.0 - 2.0 mg IV OR Diazepam 5.0 mg IV slow push. (Shivering increases metabolic heat production and retards cooling rate).")

        # Rhabdomyolysis & Fluid Resuscitation
        if d.serum_creatine_kinase_u_l >= 5000.0:
            orders.append("3. RHABDOMYOLYSIS & RENAL PROTECTION PROTOCOL:")
            orders.append("   • Administer unheated Isotonic Saline (0.9% NaCl or Plasmalyte) boluses targeting URINE OUTPUT 2.0 - 3.0 mL/kg/hr.")
            orders.append("   • Monitor serial CK, potassium, and coagulation panels q4-6h; watch for hyperkalemic cardiac arrhythmias.")

        # Antipyretic Absolute Prohibition Sentinel
        sentinels.append("🚨 ABSOLUTE ANTIPYRETIC CONTRAINDICATION (Acetaminophen, Aspirin, NSAIDs): Heat stroke is caused by thermoregulatory overwhelming, NOT prostaglandin-mediated hypothalamic set-point elevation. Acetaminophen causes fatal acute liver necrosis in hyperthermic liver injury; Aspirin/NSAIDs exacerbate coagulopathy, DIC, and renal tubular necrosis. STRICTLY PROHIBIT ANTIPYRETICS!")

        # Dantrolene Inefficacy Sentinel
        sentinels.append("🚨 DANTROLENE INEFFECTIVE: Dantrolene has zero proven therapeutic efficacy in environmental/exertional heat stroke and is contraindicated (indicated strictly for malignant hyperthermia).")

        return orders, sentinels

    def evaluate_case(self, data: HeatStrokeTelemetry) -> HeatStrokeEvaluationReport:
        is_qc_valid, sentinels_qc = self.audit_thermometry_quality(data)
        is_bouchama, bouchama_status = self.validate_bouchama_criteria(data)
        rate, rate_tier, extract_target = self.calculate_cooling_velocity(data)
        rx_orders, sentinels_rx = self.generate_resuscitation_orders(data)

        all_sentinels = sentinels_qc + sentinels_rx

        directives = []
        directives.append(f"DIAGNOSIS: {bouchama_status}.")
        directives.append(f"COOLING VELOCITY: {rate_tier}.")
        directives.append(f"EXTRACTION: {extract_target}.")
        directives.append("RESUSCITATION: Target core temp < 39.0 C within 30 minutes of collapse.")

        return HeatStrokeEvaluationReport(
            patient_id=data.patient_id,
            bouchama_diagnostic_status=bouchama_status,
            phenotype_risk_tier=data.heat_stroke_phenotype,
            observed_cooling_rate_c_min=rate,
            cooling_rate_efficacy_tier=rate_tier,
            immersion_extraction_target_c=extract_target,
            resuscitation_and_shivering_orders=rx_orders,
            safety_sentinels=all_sentinels,
            clinical_wms_acsm_directive=" ".join(directives)
        )

# Example Execution & Verification
if __name__ == "__main__":
    engine = HeatStrokeDecisionEngine()

    print("=" * 80)
    print("OpenPHR Clinical Critical Care Heat Stroke Bouchama & Core Cooling Engine")
    print("=" * 80)

    # Test Case 1: 24-year-old marathon runner presenting to Medical Tent collapsed.
    # Telemetry: Rectal Core Temp 41.6 C (106.9 F), Comatose with combativeness (Bouchama Criteria Met!).
    # Active Cooling: Cold Water Immersion (CWI). Temp dropped from 41.6 C to 39.4 C in 14 minutes.
    # Rate: (41.6 - 39.4) / 14 = 0.157 C/min (Optimal >= 0.15 C/min!).
    # Labs: CK 34,500 U/L (Severe Rhabdomyolysis), Shivering present.
    # Triage: Continue CWI until 38.6-38.9 C + IV Midazolam for Shivering + Unheated Saline 2-3 mL/kg/h!
    # Sentinels: Acetaminophen/Aspirin Prohibition + Indwelling Rectal Thermistor Mandate!
    hs1 = HeatStrokeTelemetry(
        patient_id="CRIT-HEAT-7701",
        age_years=24.0,
        patient_weight_kg=76.0,
        rectal_core_temperature_celsius=41.6,
        thermometer_site="Rectal Thermistor",
        ambient_wbgt_celsius=32.5,
        heat_stroke_phenotype="Exertional Heat Stroke (EHS)",
        activity_context="Marathon runner collapsed at mile 22",
        cns_status="Comatose / Severe Delirium with Combativeness",
        has_active_seizures=False,
        is_shivering=True,
        heart_rate_bpm=158.0,
        mean_arterial_pressure_mmhg=68.0,
        active_cooling_modality="Cold Water Immersion (CWI, 8-12 C with water circulation)",
        elapsed_cooling_minutes=14.0,
        initial_core_temp_celsius=41.6,
        current_core_temp_celsius=39.4,
        serum_creatine_kinase_u_l=34500.0,
        serum_potassium_meq_l=5.2,
        platelet_count_k_ul=112.0,
        inr=1.45,
        urine_output_ml_kg_hr=0.85
    )

    rep1 = engine.evaluate_case(hs1)

    print(f"\n[Patient {rep1.patient_id} - Heat Stroke Assessment]")
    print(f"Bouchama Status: {rep1.bouchama_diagnostic_status}")
    print(f"Phenotype: {rep1.phenotype_risk_tier}")
    print(f"Observed Cooling Rate: {rep1.observed_cooling_rate_c_min:.3f} °C/min")
    print(f"Cooling Velocity Tier: {rep1.cooling_rate_efficacy_tier}")
    print(f"\nImmersion Extraction Guidance:\n  {rep1.immersion_extraction_target_c}")
    print("\nResuscitation & Shivering Orders:")
    for o in rep1.resuscitation_and_shivering_orders:
        print(f"  {o}")
    if rep1.safety_sentinels:
        print("\nSafety Sentinels:")
        for s in rep1.safety_sentinels:
            print(f"  🚨 {s}")
    print(f"\nWMS / ACSM Consensus Directive:\n{rep1.clinical_wms_acsm_directive}")