Cookbook 371: Offline Clinical Critical Care & Nephrology Acute Rhabdomyolysis McMahon Risk Staging, Myoglobin Cast Nephropathy & Urine Alkalinization Engine

"""
Offline Clinical Critical Care & Nephrology Acute Rhabdomyolysis McMahon Risk Staging,
Myoglobin Cast Nephropathy & Urine Alkalinization Engine.
Zero external cloud API reliance. Pure offline Python.
"""

import sys
from dataclasses import dataclass, field
from enum import Enum
from typing import List, Optional

# Enforce UTF-8 standard output for Windows CLI environments
if hasattr(sys.stdout, "reconfigure"):
    sys.stdout.reconfigure(encoding="utf-8")


class RhabdoEtiology(str, Enum):
    TRAUMA_CRUSH = "Trauma / Crush Injury / Compartment Syndrome / Major Surgery (Etiology score: 0)"
    NON_TRAUMA = "Non-Trauma: Prolonged Immobilization / Sepsis / Heat Stroke / Exertional / Tox / Statins (Etiology score: 3)"


class McMahonRiskTier(str, Enum):
    LOW_RISK = "Low Risk (McMahon Score < 6.0) - Predicted RRT/Mortality Risk < 3%"
    HIGH_RISK = "High Risk (McMahon Score >= 6.0) - High Probability of Severe AKI / RRT / In-Hospital Mortality (> 85% Sensitivity)"


@dataclass
class RhabdoPatientProfile:
    patient_id: str
    age_years: int
    is_female: bool
    weight_kg: float
    etiology: RhabdoEtiology
    # Laboratory Data
    initial_serum_creatinine_mg_dl: float
    initial_serum_calcium_mg_dl: float
    initial_serum_phosphate_mg_dl: float
    initial_serum_bicarbonate_meq_l: float
    initial_or_peak_ck_u_l: float
    serum_potassium_meq_l: float = 4.8
    arterial_ph: float = 7.34
    current_urine_output_ml_h: float = 45.0
    current_urine_ph: float = 5.2
    # Compartment Syndrome Assessment
    has_limb_crush_or_tense_compartment: bool = False
    diastolic_bp_mmhg: float = 78.0
    intracompartmental_pressure_mmhg: Optional[float] = None
    has_ecg_hyperkalemia_signs: bool = False  # Peaked T waves, PR prolongation, QRS widening


@dataclass
class RhabdoResuscitationAssessment:
    patient_id: str
    mcmahon_score: float
    mcmahon_risk_tier: McMahonRiskTier
    fluid_resuscitation_prescription: str
    target_urine_output_ml_h: str
    urinary_alkalinization_prescription: str
    potassium_and_calcium_sentinels: List[str]
    compartment_syndrome_directive: str
    crrt_triage_indication: str
    safety_sentinels: List[str]
    clinical_guideline_directive: str


class RhabdomyolysisEngine:
    """
    Precision Critical Care Nephrology Decision Engine for Acute Rhabdomyolysis & Myoglobinuria.
    Conforms to KDIGO 2024, SFAR, and EAST Guidelines.
    """

    def evaluate_case(self, p: RhabdoPatientProfile) -> RhabdoResuscitationAssessment:
        sentinels: List[str] = []
        ca_k_sentinels: List[str] = []

        # 1. Calculate McMahon Risk Score (0 - 14 points)
        score = 0.0

        # Age
        if p.age_years < 50:
            score += 0.0
        elif 50 <= p.age_years <= 70:
            score += 1.5
        else:
            score += 2.5

        # Gender
        if p.is_female:
            score += 1.0

        # Etiology
        if p.etiology == RhabdoEtiology.NON_TRAUMA:
            score += 3.0

        # Serum Creatinine (initial)
        if p.initial_serum_creatinine_mg_dl < 1.4:
            score += 0.0
        elif 1.4 <= p.initial_serum_creatinine_mg_dl <= 2.2:
            score += 1.5
        else:
            score += 3.0

        # Serum Calcium (initial)
        if p.initial_serum_calcium_mg_dl < 8.0:
            score += 2.0

        # Serum Phosphate (initial)
        if p.initial_serum_phosphate_mg_dl < 4.0:
            score += 0.0
        elif 4.0 <= p.initial_serum_phosphate_mg_dl <= 5.4:
            score += 1.5
        else:
            score += 3.0

        # Serum Bicarbonate (initial)
        if p.initial_serum_bicarbonate_meq_l < 19.0:
            score += 2.0

        # Creatine Kinase (initial/peak)
        if p.initial_or_peak_ck_u_l > 40000.0:
            score += 2.0

        score = round(score, 1)

        if score >= 6.0:
            risk_tier = McMahonRiskTier.HIGH_RISK
        else:
            risk_tier = McMahonRiskTier.LOW_RISK

        # 2. Targeted Fluid Resuscitation Prescription
        if risk_tier == McMahonRiskTier.HIGH_RISK or p.initial_or_peak_ck_u_l > 15000.0:
            fluid_rate_ml_h = max(500, min(1000, round(p.weight_kg * 10.0, 0)))
            fluid_rx = (
                f"Aggressive Isotonic Crystalloid Expansion: Initiate Balanced Crystalloid (Plasma-Lyte or Lactated Ringer's) "
                f"at {fluid_rate_ml_h:.0f} mL/h ({p.weight_kg * 10.0:.0f} mL/kg/h) for the initial 2-6 hours. "
                f"Avoid large-volume 0.9% Normal Saline to prevent hyperchloremic metabolic acidosis."
            )
        else:
            fluid_rate_ml_h = max(250, min(500, round(p.weight_kg * 4.0, 0)))
            fluid_rx = (
                f"Moderate Isotonic Crystalloid Expansion: Balanced Crystalloid at {fluid_rate_ml_h:.0f} mL/h "
                f"to support renal medullary perfusion."
            )

        target_uop = "Target Urine Output: 200 - 300 mL/h (or 3.0 mL/kg/h) until serum CK falls < 5,000 U/L."

        # 3. Urinary Alkalinization Protocol
        if p.initial_or_peak_ck_u_l > 5000.0 and p.arterial_ph < 7.50 and p.initial_serum_bicarbonate_meq_l < 30.0:
            if p.initial_serum_calcium_mg_dl < 7.5 and not p.has_ecg_hyperkalemia_signs:
                alkalinization_rx = (
                    f"⚠️ URINARY ALKALINIZATION HELD: Severe initial hypocalcemia (Ca {p.initial_serum_calcium_mg_dl:.1f} mg/dL). "
                    f"Sodium bicarbonate infusion may exacerbate hypocalcemia by increasing protein binding and precipitating tetany. "
                    f"Prioritize volume expansion with balanced crystalloids."
                )
            else:
                alkalinization_rx = (
                    "Sodium Bicarbonate Urinary Alkalinization: Infuse 150 mEq NaHCO3 in 1L D5W at 150 - 250 mL/h. "
                    "Target Urine pH > 6.5 (measured hourly) to prevent intratubular ferrihemate cast precipitation and lipid peroxidation. "
                    "SAFETY STOP LIMIT: Discontinue immediately if arterial pH >= 7.50 or serum bicarbonate >= 30 mEq/L."
                )
        else:
            alkalinization_rx = (
                "Urinary alkalinization not routinely required (CK < 5,000 U/L or baseline arterial pH >= 7.50). "
                "Maintain goal urine output with balanced crystalloids."
            )

        # 4. Calcium and Potassium Sentinels
        if p.initial_serum_calcium_mg_dl < 8.5:
            if p.has_ecg_hyperkalemia_signs or p.serum_potassium_meq_l >= 6.5:
                ca_k_sentinels.append(
                    f"🚨 HYPERKALEMIA CARDIAC TOXICITY EMERGENCY (K+ {p.serum_potassium_meq_l:.1f} mEq/L): "
                    f"Administer IV Calcium Chloride 10% (10 mL = 1 gram) or Calcium Gluconate (30 mL = 3 grams) over 2-5 minutes "
                    f"for myocyte membrane stabilization, followed by Regular Insulin 10 units IV + D50W 50 mL."
                )
            else:
                ca_k_sentinels.append(
                    f"🚨 EARLY ASYMPTOMATIC HYPOCALCEMIA GUARDRAIL (Ca {p.initial_serum_calcium_mg_dl:.1f} mg/dL): "
                    f"DO NOT administer IV calcium for asymptomatic hypocalcemia. Calcium is sequestered in damaged myocytes; "
                    f"exogenous calcium causes metastatic tissue calcification and severe late rebound hypercalcemia upon muscle recovery."
                )

        if p.serum_potassium_meq_l > 5.5 and not p.has_ecg_hyperkalemia_signs:
            ca_k_sentinels.append(
                f"HYPERKALEMIA ALERT (K+ {p.serum_potassium_meq_l:.1f} mEq/L): Continuous cardiac monitoring. "
                f"Shift potassium intracellularly with Regular Insulin 10 units IV + D50W 50 mL and Nebulized Albuterol 10-20 mg."
            )

        # 5. Compartment Syndrome Assessment
        if p.has_limb_crush_or_tense_compartment:
            if p.intracompartmental_pressure_mmhg is not None:
                delta_p = p.diastolic_bp_mmhg - p.intracompartmental_pressure_mmhg
                if delta_p <= 30.0 or p.intracompartmental_pressure_mmhg >= 30.0:
                    compartment_directive = (
                        f"🚨 LEVEL 1 SURGICAL EMERGENCY: Acute Compartment Syndrome Confirmed! "
                        f"Intracompartmental Pressure = {p.intracompartmental_pressure_mmhg:.0f} mmHg, "
                        f"Delta P (Diastolic BP {p.diastolic_bp_mmhg:.0f} - ICP) = {delta_p:.0f} mmHg (<= 30 mmHg threshold). "
                        f"Immediate orthopedic / trauma surgery consultation for emergent decompressive fasciotomy!"
                    )
                    sentinels.append(compartment_directive)
                else:
                    compartment_directive = (
                        f"Compartment pressure monitored: ICP {p.intracompartmental_pressure_mmhg:.0f} mmHg, "
                        f"Delta P {delta_p:.0f} mmHg (> 30 mmHg safe margin). Serial exams q2h."
                    )
            else:
                compartment_directive = (
                    "High risk for extremity compartment syndrome: Measure intracompartmental pressures (Stryker needle) immediately. "
                    "Delta P <= 30 mmHg mandates emergent surgical fasciotomy."
                )
        else:
            compartment_directive = "No clinical evidence of extremity compartment syndrome."

        # 6. CRRT Triage
        if (
            risk_tier == McMahonRiskTier.HIGH_RISK
            and (p.serum_potassium_meq_l >= 6.5 or p.arterial_ph < 7.15 or p.current_urine_output_ml_h < 30.0)
        ):
            crrt_triage = (
                "🚨 CRRT MOBILIZATION: Patient exhibits high-risk rhabdomyolysis (McMahon >= 6.0) with "
                "refractory metabolic acidosis / oliguria / hyperkalemia unresponsive to initial fluid push. "
                "Initiate Continuous Veno-Venous Hemodiafiltration (CVVHDF) with high-volume convective clearance."
            )
        else:
            crrt_triage = "Continue targeted volume expansion and forced diuresis; monitor indications for renal replacement therapy."

        # 7. Safety Sentinels
        sentinels.append(
            "LOOP DIURETIC CONTRAINDICATION: Prohibit Furosemide / Torsemide until volume resuscitation is fully established; "
            "premature diuretics acidify tubular fluid, accelerating cast precipitation and compounding intravascular hypovolemia."
        )
        sentinels.append(
            "POTASSIUM INFUSION PROHIBITION: Prohibit all potassium-containing IV fluids (e.g., standard maintenance solutions) "
            "during acute rhabdomyolysis due to explosive endogenous potassium release from lysed muscle beds."
        )

        directive = (
            f"CLINICAL DIRECTIVE: {risk_tier.value} (McMahon Score: {score}/14). "
            f"{fluid_rx} {target_uop} {alkalinization_rx}"
        )

        return RhabdoResuscitationAssessment(
            patient_id=p.patient_id,
            mcmahon_score=score,
            mcmahon_risk_tier=risk_tier,
            fluid_resuscitation_prescription=fluid_rx,
            target_urine_output_ml_h=target_uop,
            urinary_alkalinization_prescription=alkalinization_rx,
            potassium_and_calcium_sentinels=ca_k_sentinels,
            compartment_syndrome_directive=compartment_directive,
            crrt_triage_indication=crrt_triage,
            safety_sentinels=sentinels,
            clinical_guideline_directive=directive
        )


# =====================================================================
# Verification & Self-Testing Suite
# =====================================================================
if __name__ == "__main__":
    engine = RhabdomyolysisEngine()

    print("================================================================================")
    print("DEMO 1: Severe Crush Injury Rhabdomyolysis with High McMahon Score & Compartment Syndrome")
    print("================================================================================")
    case_crush = RhabdoPatientProfile(
        patient_id="RHABDO-CRUSH-801",
        age_years=54,
        is_female=False,
        weight_kg=85.0,
        etiology=RhabdoEtiology.TRAUMA_CRUSH,
        initial_serum_creatinine_mg_dl=2.4,
        initial_serum_calcium_mg_dl=7.2,
        initial_serum_phosphate_mg_dl=5.8,
        initial_serum_bicarbonate_meq_l=16.0,
        initial_or_peak_ck_u_l=68000.0,
        serum_potassium_meq_l=6.2,
        arterial_ph=7.22,
        current_urine_output_ml_h=35.0,
        current_urine_ph=5.1,
        has_limb_crush_or_tense_compartment=True,
        diastolic_bp_mmhg=72.0,
        intracompartmental_pressure_mmhg=46.0,
        has_ecg_hyperkalemia_signs=False
    )

    res1 = engine.evaluate_case(case_crush)
    print(f"Patient ID: {res1.patient_id} ({case_crush.weight_kg} kg)")
    print(f"McMahon Score: {res1.mcmahon_score} / 14 -> {res1.mcmahon_risk_tier.value}")
    print(f"Fluid Resuscitation:\n  {res1.fluid_resuscitation_prescription}")
    print(f"Urine Target: {res1.target_urine_output_ml_h}")
    print(f"Urinary Alkalinization:\n  {res1.urinary_alkalinization_prescription}")
    print(f"Compartment Syndrome:\n  {res1.compartment_syndrome_directive}")
    print(f"CRRT Triage: {res1.crrt_triage_indication}")
    print("\nCalcium & Potassium Sentinels:")
    for s in res1.potassium_and_calcium_sentinels:
        print(f"  {s}")
    print("\nSafety Sentinels:")
    for s in res1.safety_sentinels:
        print(f"  🚨 {s}")

    print("\n================================================================================")
    print("DEMO 2: Exertional Rhabdomyolysis in Young Athlete (Low McMahon Score)")
    print("================================================================================")
    case_exert = RhabdoPatientProfile(
        patient_id="RHABDO-EXERT-802",
        age_years=24,
        is_female=True,
        weight_kg=60.0,
        etiology=RhabdoEtiology.NON_TRAUMA,
        initial_serum_creatinine_mg_dl=0.9,
        initial_serum_calcium_mg_dl=9.2,
        initial_serum_phosphate_mg_dl=3.6,
        initial_serum_bicarbonate_meq_l=24.0,
        initial_or_peak_ck_u_l=18000.0,
        serum_potassium_meq_l=4.1,
        arterial_ph=7.39,
        current_urine_output_ml_h=110.0,
        current_urine_ph=5.8
    )

    res2 = engine.evaluate_case(case_exert)
    print(f"Patient ID: {res2.patient_id} ({case_exert.weight_kg} kg)")
    print(f"McMahon Score: {res2.mcmahon_score} / 14 -> {res2.mcmahon_risk_tier.value}")
    print(f"Fluid Resuscitation:\n  {res2.fluid_resuscitation_prescription}")
    print(f"Urinary Alkalinization:\n  {res2.urinary_alkalinization_prescription}")