SHM Converge Scientific Abstract ePoster Gallery-A Crashing Patient With Brash Syndrome

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This case describes a 78-year-old man with atrial fibrillation, HFrEF, CKD, diabetes, and hypertension who presented with weeks of lethargy and confusion. He was taking multiple medications that can worsen AV nodal blockade or renal function, including metoprolol, amiodarone, lisinopril, and furosemide. On arrival, he was profoundly hypotensive and bradycardic, with signs of volume overload (crackles, edema, pulmonary edema and pleural effusions on chest X-ray). ECG showed marked bradycardia with prolonged QRS complexes. Labs revealed hyperkalemia (K 6.6), acute kidney injury (Cr 4.1 from baseline 2.5), elevated lactate, and markedly elevated NT-proBNP, consistent with shock and decompensated heart failure.<br /><br />He was diagnosed with BRASH syndrome, a clinical syndrome defined by the combination of bradycardia, renal failure, AV nodal blockade, shock, and hyperkalemia. The syndrome reflects a vicious positive feedback loop in which AV nodal blockers and hyperkalemia together cause disproportionate bradycardia, worsening renal perfusion, increasing hyperkalemia, and further destabilizing the patient.<br /><br />Management focused on simultaneously treating bradycardia and hyperkalemia. Acute therapy included IV calcium, insulin with dextrose, bicarbonate, and atropine, with epinephrine considered if bradycardia persisted. Definitive treatment of hyperkalemia depends on the patient’s volume status and renal function, using either diuresis or dialysis. In this case, he was diuresed to euvolemia with IV furosemide, home medications were held and then carefully reintroduced (except amiodarone and metformin), and he ultimately stabilized without recurrence of the initial problem. The authors emphasize that BRASH syndrome can occur in any patient on AV nodal blocking agents, especially those with renal disease, and requires prompt recognition and integrated treatment.

Asset Subtitle

Ryan E. Nelson

Meta Tag

Author List Aaron L. Troy, Hayley Zullow, Ryan E. Nelson

Category Clinical Vignettes

Concept BRASH Syndrome

Concept Bradycardia

Concept Renal Failure

Concept Atrioventricular Block

Concept Shock

Concept Hyperkalemia

Distinguished Non-Finalist

Presenter Organization Beth Israel Deaconess Medical Center, Harvard Medical School

Presenting Author Ryan E. Nelson

Track Adult

Keywords

BRASH syndrome

bradycardia

renal failure

hyperkalemia

AV nodal blockade

shock

acute kidney injury

atrial fibrillation

heart failure

electrolyte imbalance

BRASH Syndrome

Bradycardia

Renal Failure

Atrioventricular Block

Shock

Hyperkalemia