II. Definitions

  1. BRASH Syndrome
    1. Bradycardia Syndrome with Renal Failure, AV Block, Shock and Hyperkalemia

III. Findings: BRASH Syndrome

  1. Bradycardia
  2. Renal Failure
  3. AV Node Blocker (e.g. Beta Blocker or Calcium Channel Blocker)
  4. Shock (out of proportion to degree of Hyperkalemia, requires fluid Resuscitation and possible pressors)
  5. Hyperkalemia

IV. Pathophysiology

  1. Occurs in patients with both Hyperkalemia AND on AV nodal blocking agents (e.g. Beta Blocker or Calcium Channel Blocker)
  2. Profound Bradycardia, resulting in hypoperfusion and shock, and ultimately Renal Failure
  3. Other medications have been associated with BRASH
    1. Amiodarone
    2. ACE Inhibitors and Angiotensin Receptor Blockers with SGLT2 Inhibitors
      1. Nagamine (2022) CJEM 24(1): 99-100 [PubMed]

V. Precautions

  1. Key to treating BRASH Syndrome is recognizing the need for multifactorial management
  2. Even mild Hyperkalemia may worsen Bradycardia in those already on Beta Blockers

VI. Management

  1. Initiate Hyperkalemia Management
    1. See Hyperkalemia Management
    2. Initiate IV Calcium, IV Insulin and Dextrose
    3. Consider Isotonic Bicarbonate infusion with 3 ampules bicarbonate in 1 liter of D5W and give 1-2 Liters
      1. Use only if patient with acidosis and do not exceed bicarbonate deficit (risk of alkalosis)
    4. Consider Kaliuresis in End-Stage Renal Disease patients needing Dialysis (but not yet on Dialysis), but is delayed
      1. High dose Diuretics are given (e.g. lasix 180 IV and 1000 mg Chlorothiazide IV and 500 mg IV Acetazolamide)
      2. These doses are extremely high and require close monitoring of Urine Output
      3. Not typically effective in patients already on Dialysis
  2. Bradycardia
    1. See Unstable Bradycardia
    2. May improve with IV Calcium and other Acute Hyperkalemia Management
    3. Consider Epinephrine infusion for Bradycardia and Hypotension
  3. Dehydration
    1. Perform adequate fluid Resuscitation
  4. Hold or discontinue associated medications
    1. Stop Beta Blockers
    2. Stop Calcium Channel Blocker
    3. Stop ACE Inhibitors and Angiotensin Receptor Blockers

VII. References

  1. Swaminathan and Farkas in Herbert (2019) EM:Rap 19(11): 11-2
  2. Shah (2022) Eur J Intern Med 103: 57-61 +PMID: 35676108 [PubMed]

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