BRASH syndrome with a complete heart block- a case report

INTRODUCTION

BRASH syndrome (Bradycardia, Renal failure, Atrioventricular (AV) nodal blocking agent, Shock and Hyperkalemia) is a recently emerging diagnosis that describes the profound bradycardia seen in patients on AV nodal blockers who present with acute kidney injury (AKI) and hyperkalemia.

CASE PRESENTATION

We present a case of a 68 years old female patient with past history of hypertension taking atenolol and Enalapril presented to emergency department with the complaint of loss of consciousness of 02 hours duration. She had 03 days history of fatigue, poor oral intake, decreased urine output, appetite loss, vertigo and global headache. Her vital signs were blood pressure of 60/40 mmHg, absent radial pulse and temperature of 36.4 °C. Her systemic examination was remarkable for dry buccal mucosa; apical heart rate was 22 beats per minute. Glasgow Coma Scale was 13/15. Her laboratory tests showed creatinine of 1.83 mg/dL, blood urea nitrogen of 89 mg/dL and potassium elevated to the level of 6.39 mEq/dL. ECG revealed complete heart block with a normal QT interval and T waves and no U waves with ventricular rate of 22 beats per minute. Her previous medications were discontinued and the patient was resuscitated with intravenous (IV) fluids. She was given 03 doses of 1 mg atropine every 5 minutes but there was no increment in heart rate. She was given 50% dextrose with 10 international units of regular insulin, 1 g of calcium gluconate and Intravenous perfusion of norepinephrine and dopamine. Subsequently, after 14 hours of ICU admission the patient had a cardiac arrest with asystole and resuscitation was attempted but she couldn't survive.

CONCLUSION

BRASH syndrome is largely an under-recognized life threatening clinical diagnosis. Physicians should have high index of suspicion for BRASH when they encounter patients with bradycardia, hyperkalemia, and renal failure, as timely diagnosis is crucial in the management.

Rare presentation of BRASH syndrome with hypoglycemia and altered mental status

BACKGROUND

BRASH syndrome (bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia) is a rare clinical condition with potentially severe outcomes. 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.

CASE PRESENTATION

This case study presents a 74-year-old patient with a history of multiple chronic conditions who was brought to the emergency department with a suspected cerebrovascular accident, altered mental status, and bradycardia. A head computed tomography scan was unremarkable but laboratory results showed hyperkalemia, acidosis, and renal failure with concomitant progressive hypoglycemia. The patient was diagnosed with a BRASH syndrome characterized by a vicious cycle of atrioventricular nodal blockade induced by the potentiated effect of beta-blockers or calcium channel blockers, in combination with progressive hypoglycemia due to the suspected accumulation of anti-diabetic medications, which influenced the presentation and initial triage in the emergency department. She was admitted to the intensive care unit for further management, where she continued to improve and was ultimately discharged in a relatively stable condition.

CONCLUSION

This case study highlights the importance of considering rare and atypical presentations of medical conditions, particularly in elderly patients who may have multiple comorbidities. Early recognition and prompt management of such cases are crucial for improving patient outcomes.

Bradycardia, Renal Failure, Atrioventricular Nodal Blockade, Shock and Hyperkalaemia Syndrome Involving Digoxin Toxicity: A Case Report

Bradycardia, renal failure, atrioventricular nodal blockade, shock and hyperkalemia (BRASH) syndrome is named after the pentad of symptoms experienced by patients with this clinical entity, and is propagated via a synergistic mechanism. Herein, we describe a case of an 81-year-old male who presented with bradycardia, dyspnoea on exertion, and confusion. He was also initially found to be in cardiogenic shock. In a setting of elevated digoxin levels, acute renal failure and hyperkalemia, he was diagnosed with BRASH syndrome. Prompt interventions of continuous renal replacement therapy and digoxin antibody administration were performed to treat this patient. His renal function improved and his hyperkalemia and bradycardia resolved over the course of 4 days, and the patient was discharged to a subacute rehabilitation facility after stabilization. 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.

Anaphylaxis induced bradycardia, renal failure, AV-nodal blockade, shock, and hyperkalemia: A-BRASH in the emergency department

The emergency department (ED) is responsible for managing a variety of acute illnesses including undifferentiated shock. A newer less recognized syndrome termed BRASH - bradycardia, renal failure, AV-node blockers, shock and hyperkalemia - is a cycle of synergy between hyperkalemia and AV-blockade that can result in shock. This entity is more common amongst the elderly, considering polypharmacy and co-morbid diseases. Some cases have an inciting trigger of hypovolemia. Anaphylaxis is a potentially lethal form of shock that most emergency physicians (EP) treat in the ED. The two entities have never occurred simultaneously. Herein, we report a case of anaphylaxis induced BRASH syndrome occurring in an elderly diabetic man. The EP should be aware of this unique presentation of BRASH. It was concluded that the patient's anaphylaxis, caused hypovolemia, coupled with polypharmacy, and physiological stress, precipitated this severe form of shock and multi-organ system failure.