🫀 Interná medicína · 3

Šok (typy šoku, diagnostika, liečba)

Definícia

• Šok je hypoperfúzia tkanív pri akútnom zlyhaní obehu s nedostatočnou dodávkou kyslíka do tkanív, ktorá vedie k dysfunkcii a poškodeniu buniek. Podľa mechanizmu sa delí na hypovolemický, kardiogénny, obštrukčný a distributívny; typy sa môžu vyskytovať samostatne aj v kombinácii.

Etiológia a patogenéza

• Hypovolemický šok: kritický pokles intravaskulárneho objemu – napr. krvácanie (trauma, operácia, peptický vred, pažerákové varixy, ruptúra aneuryzmy aorty) alebo nehemoragické straty telesných tekutín.
• Kardiogénny šok: zníženie srdcového výdaja pri primárnej poruche srdca; príčinou je napr. akútny infarkt myokardu, arytmie, akútna mitrálna regurgitácia (ruptúra papilárneho svalu) alebo ruptúra komorového septa.
• Obštrukčný šok: mechanická prekážka plneniu alebo vyprázdňovaniu srdca či veľkých ciev – napr. tenzný pneumotorax, tamponáda srdca.
• Distributívny šok: relatívny nedostatok intravaskulárneho objemu pri artériovej alebo venóznej vazodilatácii; na urgentnom príjme sú najčastejšími príčinami sepsa a anafylaxia, ďalej napr. neurogénny šok pri ťažkom poranení miechy (zvyčajne nad T4).

Klinický obraz

• Typické prejavy sú napr. porucha vedomia, tachykardia, hypotenzia a oligúria; hypotenzia (systolický TK < 90 mmHg alebo MAP < 65 mmHg) je častá, ale nie je podmienkou diagnózy.
• Pri hypovolemickom, kardiogénnom a obštrukčnom šoku je predĺžený kapilárny návrat; pri distributívnom môže byť kapilárny návrat normálny, koža teplá a pulz skákavý.
• Tamponádu srdca naznačuje distenzia krčných žíl, tlmené ozvy a paradoxný pulz.
• Kardiogénny šok – klasický (štádium C podľa SCAI): hypoperfúzia neliečená alebo vyžadujúca farmakologickú či mechanickú podporu obehu; pacienti majú typicky relatívnu hypotenziu, hypotenzia však nie je podmienkou.

Diagnostika

• Diagnóza je prevažne klinická (anamnéza a známky hypoperfúzie); pri podozrení na šok sa pacient vyšetruje systematicky postupom ABCDE.
• Laktát > 2 mmol/l svedčí o hypoperfúzii tkanív; laboratórne nálezy sa hodnotia v trende a v celkovom klinickom kontexte, žiadny samostatne nie je diagnostický.
• Echokardiografia hodnotí srdcový výdaj; bedside ultrazvuk (POCUS) posudzuje plnenie a funkciu srdca a objemový stav a možno ho opakovať.
• Tiaž kardiogénneho šoku sa stratifikuje štádiami SCAI: A – riziko šoku, B – začínajúci šok (hemodynamická nestabilita so zachovanou perfúziou), C – klasický šok (hypoperfúzia), D – zhoršovanie (zlyhanie úvodnej podpornej liečby), E – extrémny (refraktérny šok s prebiehajúcim alebo hroziacim kolapsom obehu napriek vysokej a stúpajúcej podpore, vrátane prebiehajúcej zástavy obehu).

Liečba

• Hypovolemický a distributívny (vrátane septického) šok: úvodne zvyčajne tekutiny, napr. 30 ml/kg vyváženého kryštaloidu počas 3 hodín; menšie objemy (napr. 250–500 ml) pri známkach vysokého pravostranného tlaku alebo akútnom IM; pri edéme pľúc sa tekutinová výzva zvyčajne nerobí.
• Hemoragický šok: prioritou je chirurgické zastavenie krvácania; pri masívnej transfúzii erytrocyty, plazma a trombocyty v pomere 1:1:1; do kontroly krvácania permisívna hypotenzia (systolický TK 80–90 mmHg), ktorá je kontraindikovaná pri kraniocerebrálnom poranení.
• Septický šok (SSC 2026): antimikrobiálna liečba ihneď, ideálne do 1 hodiny od rozpoznania; noradrenalín ako vazopresor 1. voľby; iniciálny cieľ MAP 65 mmHg, u osôb ≥ 65 rokov iniciálne rozmedzie 60–65 mmHg.
• Kardiogénny šok pri IM: štandardom je čo najskoršia obnova koronárneho prietoku (revaskularizácia); dočasná mechanická podpora obehu sa neodporúča u neselektovaných pacientov s kardiogénnym šokom pri akútnom IM (ESC 2026), u vybraných sa má zvážiť (napr. mikroaxiálna pumpa pri STEMI s dysfunkciou ĽK bez rizika hypoxického poškodenia mozgu).

Komplikácie a prognóza

• Syndróm multiorgánovej dysfunkcie (MODS) – progresívna dysfunkcia ≥ 2 orgánov; môže nasledovať po akomkoľvek type šoku, najčastejšie pri sepse.
• Postihnutý môže byť ktorýkoľvek orgán, napr. pľúca (ARDS) alebo obličky (akútna tubulárna nekróza so zlyhaním obličiek, oligúriou a rastom kreatinínu).
• Diseminovaná intravaskulárna koagulácia.
• Neliečený šok je zvyčajne smrteľný; aj pri liečbe je mortalita vysoká, napr. pri kardiogénnom šoku po IM 40–50 %.

Kľúčové pojmy

šok
hypovolemický šok
kardiogénny šok
obštrukčný šok
distributívny šok
septický šok
anafylaktický šok
neurogénny šok
tamponáda srdca	tamponada cordis
stredný artériový tlak (MAP)
noradrenalín	noradrenalinum

📎 Zdroje:

Shock - MSD Manual Professional Edition (Full Review Jun 2026) (definícia)Shock is tissue hypoperfusion caused by acute circulatory failure with inadequate oxygen delivery to tissues with resultant cellular dysfunction and damage.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (definícia)Shock is classified based on mechanism into the following 4 types, which can occur alone or in combination
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (definícia)Shock is classified by mechanism: hypovolemic, cardiogenic, obstructive, and/or distributive.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (etiology[0])Hypovolemic shock is caused by a critical decrease in intravascular volume.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (etiology[0])A common cause is bleeding (hemorrhagic shock), typically due to trauma, surgical interventions, peptic ulcer, esophageal varices, or ruptured aortic aneurysm
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (etiology[0])Hypovolemic shock may also follow increased losses of body fluids other than blood
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (etiology[1])Cardiogenic shock is a relative or absolute reduction in cardiac output due to a primary cardiac disorder (eg, myocardial infarction or arrhythmia)
Cardiogenic Shock - StatPearls - NCBI Bookshelf (etiology[1])The most common cause of cardiogenic shock is acute myocardial infarction
Cardiogenic Shock - StatPearls - NCBI Bookshelf (etiology[1])Mechanical defect: acute mitral regurgitation (papillary muscle rupture), ventricular wall rupture (septal or free wall)
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (etiology[2])Obstructive shock is caused by mechanical factors that interfere with filling or emptying of the heart or great vessels (eg, tension pneumothorax, cardiac tamponade).
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (etiology[3])Distributive shock results from a relative inadequacy of intravascular volume caused by arterial or venous vasodilation; circulating blood volume is normal
Distributive Shock - StatPearls - NCBI Bookshelf (etiology[3])The most common causes of distributive shock in the emergency department are sepsis and anaphylaxis.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (etiology[3])Severe injury to the spinal cord, usually above T4 (neurogenic shock)
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (clinical[0])Symptoms include altered mental status, tachycardia, hypotension, and oliguria.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (clinical[0])Hypotension (systolic blood pressure < 90 mm Hg or mean arterial pressure < 65 mm Hg) is common in patients with shock but not required.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (clinical[1])Capillary filling time is prolonged in hypovolemic, cardiogenic, and obstructive shock, as a result of compensatory vasoconstriction
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (clinical[1])However, in distributive shock, capillary filling time may be normal because of vasodilation, and the skin may appear warm or flushed, especially during sepsis. The pulse may be bounding rather than weak.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (clinical[2])Cardiac tamponade is suggested by jugular venous distention, muffled heart sounds, and a paradoxical pulse.
SCAI SHOCK Stage Classification Expert Consensus Update (J Soc Cardiovasc Angiogr Interv, PMC) (clinical[3])Stage C represents the more classic patients with CS who present with hypoperfusion either untreated or requiring hemodynamic support through pharmacologic or mechanical intervention.
SCAI SHOCK Stage Classification Expert Consensus Update (J Soc Cardiovasc Angiogr Interv, PMC) (clinical[3])These patients typically present with relative hypotension (but hypotension is not required).
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (diagnostics[0])Diagnosis is mostly clinical, based on characteristic signs and symptoms and sometimes supported by measurement of markers of tissue hypoperfusion (eg, blood lactate, base deficit).
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (diagnostics[0])Patients with suspected shock undergo an initial evaluation using a systematic ABCDE approach.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (diagnostics[1])Lactate: > 2 mmol/L (18 mg/dL) indicates tissue hypoperfusion
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (diagnostics[1])However, none of these findings alone is diagnostic, and each is evaluated by its trend (ie, worsening or improving) and in the overall clinical context, including physical signs.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (diagnostics[2])An echocardiogram is performed to assess cardiac output, and chest radiograph is typically performed.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (diagnostics[2])Rapid point-of-care ultrasound to assess adequacy of cardiac filling and function and assess volume status is often used and can be repeated frequently to evaluate progression of clinical course
SCAI SHOCK Stage Classification Expert Consensus Update (J Soc Cardiovasc Angiogr Interv, PMC) (diagnostics[3])SCAI SHOCK stage A is broad and represents the myriad of stable patients who have acute cardiac diagnoses that place them at risk for CS but fail to meet the criteria for preshock (stage B) or shock (stages C-E).
SCAI SHOCK Stage Classification Expert Consensus Update (J Soc Cardiovasc Angiogr Interv, PMC) (diagnostics[3])Stage B represents patients who have intact systemic perfusion with evidence of hemodynamic instability, such as hypotension or compensatory tachycardia
SCAI SHOCK Stage Classification Expert Consensus Update (J Soc Cardiovasc Angiogr Interv, PMC) (diagnostics[3])Stage C represents the more classic patients with CS who present with hypoperfusion either untreated or requiring hemodynamic support through pharmacologic or mechanical intervention.
SCAI SHOCK Stage Classification Expert Consensus Update (J Soc Cardiovasc Angiogr Interv, PMC) (diagnostics[3])Stage D represents the failure of an adequate trial of an initial supportive intervention
SCAI SHOCK Stage Classification Expert Consensus Update (J Soc Cardiovasc Angiogr Interv, PMC) (diagnostics[3])Stage E is reserved for refractory shock with actual or impending cardiovascular collapse despite high and escalating levels of support (including arrest-in-progress).
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (treatment[0])Typically, initial management of hypovolemic or distributive shock (including septic shock) is with fluid resuscitation: 30 mL/kg of balanced crystalloid solution, infused over 3 hours
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (treatment[0])Smaller volumes (eg, 250 to 500 mL) are used for patients with signs of high right-sided pressure (eg, distention of neck veins) or acute myocardial infarction. In addition, a fluid challenge is typically not performed in a patient with signs of pulmonary edema.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (treatment[1])In hemorrhagic shock, surgical control of bleeding is the first priority.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (treatment[1])Blood products--red blood cells, fresh frozen plasma, and platelets--are given as soon as possible and in a ratio of 1:1:1 in patients requiring massive transfusion.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (treatment[1])maintaining a goal systolic blood pressure of 80 to 90 mm Hg or MAP of 55 to 60 mm Hg; called hypotensive resuscitation or permissive hypotension) is recommended in most patients with hemorrhage shock until definitive hemorrhage control is achieved
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (treatment[1])however maintaining hypotension is contraindicated in patients with traumatic brain injury and may result in worsened outcomes
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[2])For adults with possible, probable, or definite septic shock, we “recommend” administering antimicrobial therapy immediately, ideally within 1 hr of recognition.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[2])For adults with septic shock, we “recommend” using norepinephrine as the first-line agent over dopamine, epinephrine, or selepressin.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[2])For adults with septic shock, we “recommend” an initial MAP target of 65 mm Hg over higher MAP targets.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[2])For adults with septic shock 65 years old or older, we “suggest” an initial MAP range of 60-65 mm Hg over higher ranges.
Cardiogenic Shock - StatPearls - NCBI Bookshelf (treatment[3])Early restoration of coronary blood is the most important intervention and is the standard therapy for patients with cardiogenic shock due to myocardial infarction.
New 2026 ESC Management of Heart Failure Guideline – Key Highlights (Guideline Central) (treatment[3])Temporary MCS is not recommended in unselected patients with cardiogenic shock caused by acute MI, due to risk of harm.
New 2026 ESC Management of Heart Failure Guideline – Key Highlights (Guideline Central) (treatment[3])Temporary MCS with a microaxial flow pump should be considered in selected patients with cardiogenic shock caused by ST-elevation MI with LV systolic dysfunction and no risk of hypoxic brain injury in order to reduce the risk of death.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (complications[0])Multiple organ dysfunction syndrome is the progressive dysfunction of ≥ 2 organs due to life-threatening illness or injury.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (complications[0])MODS can follow any type of shock but is most common when sepsis is the cause.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (complications[1])Any organ system can be affected.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (complications[1])This condition is termed acute lung injury or, if severe, acute respiratory distress syndrome (ARDS).
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (complications[1])The kidneys are injured when renal perfusion is critically reduced, leading to acute tubular necrosis and kidney failure manifested by oliguria and a progressive rise in serum creatinine.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (complications[2])Disseminated intravascular coagulation can sometimes result from activation of these cascades.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (complications[3])Untreated shock is usually fatal. Even with treatment, mortality from cardiogenic shock after MI (40 to 50%) and septic shock (30 to 40%) is high

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Kartičky

Vymenujte 4 základné typy šoku a uveďte príklady príčin.

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Popíšte úvodnú liečbu septického šoku podľa Surviving Sepsis Campaign 2026.

Najprv si odpoveď povedz nahlas alebo v duchu – až potom ju odkry.