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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