Jason Langenfeld, MD
Physician
University of Nebraska Medical Center, United States
Disclosure information not submitted.
Title: A Case of BRASH (Bradycardia, Renal Failure, AV blockade, Shock, Hyperkalemia) Syndrome
Case Report Body:
Introduction: BRASH syndrome is an often-missed collection of findings that create a dangerous cycle when renal failure causes hyperkalemia and accumulation of AV nodal blockers. That leads to bradycardia, hypoperfusion, worsening renal failure, eventually resulting in shock.
Description: A 72-year-old male presented to the emergency department from his rehabilitation facility where he had been recovering following hip surgery. He is on verapamil and metoprolol for home medications. At his facility he had gone unresponsive and was shocked via an AED and consciousness was regained. On arrival to the emergency department the patient was awake but altered, in a junctional bradycardia with rates of 30-40, hypotension with systolic pressure of 60-70 and hypoxia on oxygen.
Immediate interventions included intravenous fluids, 2mg of atropine, epinephrine, norepinephrine, and dopamine infusions with minimal improvement in heart rate and blood pressure.
Lab results showed a potassium of 6.9 mmol/L, pH of 7.19, pCO2 of 51 mmHg, bicarbonate of 19.5mmol/L and a blood glucose of 23mg/dl. Dextrose, insulin, calcium gluconate, and albuterol were given for hyperkalemia. Point-of-care echocardiogram showed global hypokinesis with right ventricular (RV) dysfunction, and CT angiography was negative for pulmonary embolism.
Hypoxia and respiratory failure persisted despite BiPAP, and the patient was intubated. An emergent hemodialysis catheter was placed, and the patient was started on continuous veno-venous hemodialysis (CVVHD). Over two days, the patient steadily improved and was eventually extubated. Pressors were weaned and CVVHD was discontinued. He was then discharged back to his rehab facility.
Two weeks later, he presented with a similar clinical picture and was diagnosed again with BRASH. It was found that metoprolol and verapamil were not discontinued on initial discharge. He again recovered with treatment and had resolution of his renal function. AV blocking medications were discontinued, and he has had no further occurrences.
Discussion: BRASH should be considered in patients who present with bradycardia, renal failure, shock, and hyperkalemia in the setting of AV nodal blocking medications. This case highlights the importance of recognizing this constellation of findings and treating aggressively to break the BRASH cycle.