BRASH Syndrome – Diagnosis and Treatment
Cardiovascular, Critical Care / Resuscitation
- BRASH syndrome is defined as a combination of Bradycardia, Renal failure, AV node blocker, Shock, and Hyperkalemia.
- 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.
- Little is known about epidemiology, but cases are typically in the elderly with cardiac disease and decreased kidney function.
- Often refractory to typical chronotropic agents and inadequately treated by ACLS algorithm for bradycardia.
- There is no formally defined clinical criteria used to make the diagnosis.
- Presentation may vary from asymptomatic bradycardia to shock.
- Precipitants described in case reports include hypovolemia/dehydration or medications that promote hyperkalemia or renal injury (e.g. ACEi, ARB, digitalis, beta blockers.)
- Key features of BRASH differentiating it from isolated hyperkalemia or intoxication from AV node blocking medications.
- The degree of hyperkalemia is moderate and out of proportion to the observed bradycardia. Typically, isolated hyperkalemia must be severe (~ 7mEq/L) before causing bradycardia.
- ECG may show bradycardia without other features of hyperkalemia.
- Patients are taking their AV node blocking as directed.
- There is no standard treatment algorithm. The following suggestions are based on expert opinion from a review by Farkas et al. 2020.
- The goal is to treat all aspects of BRASH syndrome simultaneously rather than fixating on one problem (e.g. bradycardia).
- Treat hyperkalemia even if it appears mild
- Insulin 5 units IV bolus +/- dextrose.
- Calcium gluconate 3g IV (peripheral) or Calcium chloride 1 g IV (central line).
- Diuresis for potassium elimination. Dosing will depend on the degree of renal dysfunction. Replace lost fluids as necessary to maintain euvolemia.
- Dialysis if refractory to diuresis.
- Treat bradycardia
- IV calcium as above.
- Epinephrine infusion starting at 1 mcg/min if ongoing bradycardia with hypotension.
- Isoproterenol infusion can be an effective alternative if epinephrine fails.
- Transvenous pacing is the last resort.
- Target euvolemia with balanced crystalloids.
- Review medications. Hold AV node blockers, antihypertensives, nephrotoxins.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
The literature on BRASH syndrome is sparse and consists of a few case reports. Treatment suggestions are based on case reports and expert opinion.
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.
Ravioli S, Woitok BK, Lindner G. BRASH syndrome – fact or fiction? A first analysis of the prevalence and relevance of a newly described syndrome. Eur J Emerg Med. 2021 Apr 1;28(2):153-155. doi: 10.1097/MEJ.0000000000000762. PMID: 33674517.
Arif AW, Khan MS, Masri A, Mba B, Talha Ayub M, Doukky R. BRASH Syndrome with Hyperkalemia: An Under-Recognized Clinical Condition. Methodist Debakey Cardiovasc J. 2020 Jul-Sep;16(3):241-244. doi: 10.14797/mdcj-16-3-241. PMID: 33133361; PMCID: PMC7587309.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Feb 17, 2022
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