SHM Converge Scientific Abstract ePoster Gallery-Break the Cycle! Cardiac Arrest Due to Brash Syndrome

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A 91-year-old man with coronary artery disease and heart failure with reduced ejection fraction collapsed at home and was found to be bradycardic with altered mental status. In the emergency setting, he had recurrent sinus bradycardia with first-degree AV block, required intubation for poor responsiveness, and improved on an epinephrine infusion. Laboratory studies revealed hyperkalemia (K 6.4 mEq/L) and acute kidney injury. He was taking valsartan, spironolactone, and metoprolol, which likely contributed to his presentation. Cardiology did not recommend pacemaker placement.<br /><br />The constellation of bradycardia, renal failure, AV-nodal blocker use, shock, and hyperkalemia led to the diagnosis of BRASH syndrome. The authors emphasize that BRASH is a vicious cycle in which hyperkalemia and AV-nodal blocking medications cause bradycardia, which lowers cardiac output, worsens renal perfusion, and further increases potassium. If untreated, this can progress to shock and multiorgan failure.<br /><br />Management requires treating all components of the syndrome. Even mild hyperkalemia should be addressed with intravenous calcium, insulin with dextrose, and supportive care. Calcium is also the first-line treatment for bradycardia in BRASH syndrome. If bradycardia persists, epinephrine infusion should be started early, with transvenous pacing reserved for refractory cases. Fluid status should be assessed carefully and hypovolemia corrected when present.<br /><br />The patient was ultimately discharged after stopping valsartan, spironolactone, and metoprolol, and follow-up monitoring showed no significant recurrent arrhythmia. The case highlights the importance of recognizing BRASH syndrome early to avoid unnecessary interventions and reduce morbidity and mortality.

Asset Subtitle

Bridget Hottenstein

Meta Tag

Author List Bridget Hottenstein, Vijairam Selvaraj

Category Clinical Vignettes

Concept BRASH Syndrome

Concept Bradycardia

Concept Hyperkalemia

Concept Renal Failure

Concept Atrioventricular Nodal Blocker

Distinguished Non-Finalist

Presenter Organization The Miriam Hospital, Providence, Rhode Island

Presenting Author Bridget Hottenstein

Track Adult

Keywords

BRASH syndrome

bradycardia

hyperkalemia

acute kidney injury

AV nodal blocker

sinus bradycardia

first-degree AV block

epinephrine infusion

heart failure

coronary artery disease

BRASH Syndrome

Bradycardia

Hyperkalemia

Renal Failure

Atrioventricular Nodal Blocker