II. Definitions
- BRASH Syndrome
- Bradycardia Syndrome with Renal Failure, AV Block, Shock and Hyperkalemia
III. Findings: BRASH Syndrome
- Bradycardia
- Renal Failure
- AV Node Blocker (e.g. Beta Blocker or Calcium Channel Blocker)
- Shock (out of proportion to degree of Hyperkalemia, requires fluid Resuscitation and possible pressors)
- Hyperkalemia
IV. Pathophysiology
- Occurs in patients with both Hyperkalemia AND on AV nodal blocking agents (e.g. Beta Blocker or Calcium Channel Blocker)
- Profound Bradycardia, resulting in hypoperfusion and shock, and ultimately Renal Failure
- Other medications have been associated with BRASH
V. Precautions
- Key to treating BRASH Syndrome is recognizing the need for multifactorial management
- Even mild Hyperkalemia may worsen Bradycardia in those already on Beta Blockers
VI. Management
- Initiate Hyperkalemia Management
- See Hyperkalemia Management
- Initiate IV Calcium, IV Insulin and Dextrose
- Consider Isotonic Bicarbonate infusion with 3 ampules bicarbonate in 1 liter of D5W and give 1-2 Liters
- Use only if patient with acidosis and do not exceed bicarbonate deficit (risk of alkalosis)
- Consider Kaliuresis in End-Stage Renal Disease patients needing Dialysis (but not yet on Dialysis), but is delayed
- High dose Diuretics are given (e.g. lasix 180 IV and 1000 mg Chlorothiazide IV and 500 mg IV Acetazolamide)
- These doses are extremely high and require close monitoring of Urine Output
- Not typically effective in patients already on Dialysis
-
Bradycardia
- See Unstable Bradycardia
- May improve with IV Calcium and other Acute Hyperkalemia Management
- Consider Epinephrine infusion for Bradycardia and Hypotension
-
Dehydration
- Perform adequate fluid Resuscitation
- Hold or discontinue associated medications
- Stop Beta Blockers
- Stop Calcium Channel Blocker
- Stop ACE Inhibitors and Angiotensin Receptor Blockers
VII. References
- Swaminathan and Farkas in Herbert (2019) EM:Rap 19(11): 11-2
- Shah (2022) Eur J Intern Med 103: 57-61 +PMID: 35676108 [PubMed]