BRASH Syndrome
When first encountered, it may seem bewildering and difficult to treat. Indeed, standard ACLS algorithms may fail with these patients. However, once understood, this disorder is easily treated and patients typically improve rapidly - Josh Farkas
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HWN Suggests
BRASH: recognizing a potentially deadly syndrome in the ED
The inciting factor is generally considered to be something that prompts acute kidney injury, often hypovolemia of some sort. Rather than AV nodal blocker overdose or severe hyperkalemia causing conduction problems, the combination of AV nodal blocker use (most often beta-blockers, but can be any type) and hyperkalemia (often only moderate) has a synergistic effect on cardiac conduction with ensuing bradycardia that can devolve into a cycle of worsening renal perfusion and shock.
Treatment is supportive, but most effective when the syndrome is recognized and all parts simultaneously managed.
Featured
BRASH Syndrome: A Vicious Cycle
BRASH syndrome is an uncommon but often fatal condition in which an acute renal injury initiates a vicious cycle of bradycardia, hyperkalemia, hypotension and worsening renal failure in patients who take AV-nodal blocking medications.
Articles of Interest
BRASH syndrome: more than just syncope
The pentad of bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia describes the BRASH syndrome, a newly recognized phenomenon in which accumulation of potassium and renally excreted atrioventricular nodal blockers cause a cycle of bradycardia, hypoperfusion, and worsening renal function.
Bradycardia, Renal Failure, Atrioventricular Nodal Blockade, Shock and Hyperkalemia Syndrome Involving Digoxin Toxicity: A Case Report
BRASH syndrome is a clinical entity requiring prompt diagnosis for life-saving treatment, including renal replacement therapy, vasoactive medications, transvenous pacing, and reversing agents, when appropriate.
BRASH Syndrome
BRASH syndrome is a combination of Bradycardia, Renal failure, AV(atrioventricular) nodal blockade, Shock, and Hyperkalemia. It is clinically essential to take these manifestations as a syndrome rather than isolated findings because they are interrelated and have synergistic effects. The most common error in managing BRASH syndrome is focusing on a single component of the syndrome (e.g. hyperkalemia) meanwhile, other aspects of the syndrome are overlooked.
BRASH Syndrome – Diagnosis and Treatment
Characterized by profound bradycardia out of proportion to the degree of hyperkalemia or use of AV node blocking medication. If untreated, it can progress to shock and multi-organ failure. This is a rare clinical syndrome recently described in multiple case reports.
BRASH syndrome: an emerging emergency
In patients with syncope, BRASH syndrome should be considered when bradycardia is associated with hyperkalaemia, without classic ECG changes, along with a history of AVN blocker use. It is important to recognise so that appropriate therapy can be instituted that addresses all the elements of the syndrome, rather than focusing on a single component.
BRASH syndrome: Bradycardia, Renal failure, Av blocker, Shock, Hyperkalemia
The treatment of BRASH syndrome centers around aggressive therapy for hyperkalemia. Additionally, many patients require a catecholamine infusion to support their perfusion.
EMNote
BRASH syndrome may present with heterogeneous, nonspecific symptoms, including generalized weakness, dizziness, and syncope, which could be easily misdiagnosed if clinicians are unaware of the association between AV nodal blocking agents and the possible consequences of bradycardia, renal injury, and shock. Cardiac pacing is rarely needed.
Episode 89- Let’s talk BRASH
Remember that this syndrome is dependent on the synergistic effects of AKI, taking an AV-nodal blocker, and hyperkalemia—typically neither one of these by itself would cause the constellation of symptoms that we see. This is evidenced by ½ of all patients not having a severe hyperkalemia or a severe enough AKI to cause circulatory shock alone. It also doesn’t fit with pure AV-node blocker toxicity since patients report taking their meds as directed.
Rare presentation of BRASH syndrome with hypoglycemia and altered mental status
Patients with BRASH syndrome can present with diverse signs and symptoms and are usually in critical condition, but if recognized early, the syndrome is treatable and may have a favorable prognosis.
Resources
StatPearls
The BRASH acronym is used to describe a syndrome where the synergistic effects of AV nodal blockers and renal impairment lead to severe bradycardia and hyperkalemia. It is named after the signs associated with this condition: Bradycardia, Renal Failure, AV nodal blockade, Shock, and Hyperkalemia.
