 Welcome back to emergency medicine video on shock. We'll finish up with cardiogenic shock and anaphylactic shock. First, cardiogenic shock. Cardiogenic shock happens when the heart is not pumping effectively. It can be caused by acute coronary syndrome, so ischemia or infarct, a valve problem, or from arrhythmias. The cardiogenic shock patient will be in cool shock. There will be tachycardic with cool extremities and pulmonary refill. There will be peripherally shut down. On top of tachycardia, they will also have a narrow pulse pressure. If the cardiogenic shock is because of ACS or MI, they might be complaining of chest pain. If it is because of arrhythmia, the patient might be complaining of palpitations. If it is a valvular problem, the patient may be complaining of shortness of breath. On examination, you might notice that the patient might have a high JVP because of poor filling. Depending on the etiology of the cardiogenic shock, our diagnosis tool differ. If we're suspicious of an ACS or MI, then diagnosis is done by sero-EKG and cardiac enzymes. If this is a valvular problem, then an ultrasound will be helpful. If this is caused from an arrhythmia, then an ECG and cardiac monitoring might be helpful. The treatment for cardiogenic shock obviously depends on the etiology. The cardiogenic shock patient needs judicious fluid since they might easily go into pulmonary edema due to poor cardiac output. These patients should be given small boluses of fluid in the range of 250 to 500 cc. And we need to watch the respiratory status very closely. Sometimes vasopressors such as dobutamine might be helpful in these cases. Other than supportive treatment, these patients need very specific treatment for their underlying etiology. For ACS, reperfusion is key. Other by stenting or thrombolysis. If it is a valve problem, sometimes urgent surgery is needed. If this is an arrhythmia, either an anti-arhythmic or defibrillating the heart might be needed. Let's switch our focus to anaphylactic shock. Anaphylactic shock, as the name suggests, comes from an allergen. An allergen that the patient is previously sensitized to. From the response of the body, the chemicals released from mast cells and basophils cause significant vasodilation in the periphery. That, in turn, causes decreased intravascular volume. That will lead to shock. The anaphylactic shock patient's skin will be warm and flush just like the septic shock patient because of the peripheral vasodilation. They might also have hives on their body or angioedema in their airway. You might be able to get an exposure to allergen history and the rapid onset of symptoms after the exposure. That will give you some clue that this could be an anaphylactic shock. In anaphylactic shock, the treatment focus on the airway since anaphylaxis or the angioedema from it can cause significant airway swelling. That makes airway management very difficult. The medication we give is epinephrine intramuscularly. We use the 1 in 1000 concentration to give either IM or in some cases of Q. If that does not decrease the swelling in the airway, we may have to give repeated doses of the 1 in 1000 epinephrine. If the patient is in shock after the 1 in 1000 epinephrine intramuscularly, we often give intravenous fluid as well. If there is still inadequate tissue perfusion, we now start to give epinephrine IV as an infusion. Remember, this dose we use a 1 in 10,000 epinephrine to use for an IV infusion. That usually will bring up the blood pressure and maintain tissue perfusion. There are other medications we also give for anaphylaxis as well. They include antihistamines and steroids. Please refer to the anaphylaxis video for further discussion. After all the ABC approach and the specific treatment for the specific kind of shock, how do we know when it is reversed? Shock is judged to be treated successfully when the vital signs have normalized and there are no signs of end-organ dysfunction. The lactate level, which is a marker of poor perfusion, should decrease as the patient is getting better. In this series on shock, we discuss the general approach to the shock patient using the ABC approach and add in IV fluids and vasopressors. We also discuss the 5 different kind of shock, septic, hypovolemic, obstructive, cardiogenic and anaphylactic. Thank you very much for watching. Thank you.