Episode 991: BRASH

Contributor: Aaron Lessen, MD

Educational Pearls

BRASH Syndrome:

• Bradycardia

• Renal Failure

• AV Nodal Blockade

• Shock

• Hyperkalemia 

Clinical Features:

• Profound bradycardia and shock in patients on AV nodal blockers:

• Commonly, Beta Blockers or Calcium Channel Blockers

Etiology: 

• Caused by an inciting kidney injury:

• Common triggers include precipitating illness, dehydration, or medications 

• Results in hyperkalemia

• The enhanced effect of the combination of AV nodal blockade and hyperkalemia leads to a more profound presentation of shock.

Treatment: 

• IV Fluids, unless volume overloaded

• Epinephrine for bradycardia

• Lasix for volume overload, only if the patient is still making urine

• Low threshold to dialyze for hyperkalemia

• Focus on treating early and more aggressively. 

References:

Farkas JD, Long B, Koyfman A, Menson K. BRASH Syndrome: Bradycardia, Renal Failure, AV Blockade, Shock, and Hyperkalemia. J Emerg Med. 2020 Aug;59(2):216-223. doi: 10.1016/j.jemermed.2020.05.001. Epub 2020 Jun 18. PMID: 32565167.

 

Summarized by Ashley Lyons OMS3

Editting by Ashley Lyons OMS3 and Jeffrey Olson MS4

 

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