Cardiovascular Medicine Book

Information Resources


BRASH Syndrome

Aka: BRASH Syndrome, Bradycardia Syndrome with Renal Failure, AV Block, Shock and Hyperkalemia
  1. Definitions
    1. BRASH Syndrome
      1. Bradycardia Syndrome with Renal Failure, AV Block, Shock and Hyperkalemia
  2. 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
  3. 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
  4. 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
  5. 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
  6. References
    1. Swaminathan and Farkas in Herbert (2019) EM:Rap 19(11): 11-2

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