From the Research
BRASH syndrome is a life-threatening condition that requires immediate medical attention with a multi-faceted treatment approach, prioritizing the management of hyperkalemia, renal dysfunction, and AV nodal blockade to prevent morbidity, mortality, and improve quality of life. The syndrome is characterized by Bradycardia, Renal failure, AV nodal blockade, Shock, and Hyperkalemia, and its management differs from the standard bradycardia algorithm in advanced cardiac life support (ACLS) 1. Initial management includes calcium gluconate (1-2 grams IV) to stabilize cardiac membranes, insulin (10 units regular insulin IV with 25g dextrose) and sodium bicarbonate (50-100 mEq IV) to shift potassium intracellularly, and diuretics or dialysis for potassium removal 2, 3, 4. Vasopressors like norepinephrine may be needed for hypotension, and temporary cardiac pacing might be required for severe bradycardia. The syndrome occurs through a dangerous synergistic interaction between hyperkalemia, renal dysfunction, and medications that affect the AV node (like beta-blockers or calcium channel blockers), creating a vicious cycle where hyperkalemia worsens bradycardia, reduced cardiac output impairs renal function, and kidney injury leads to medication accumulation and worsening hyperkalemia 5.
Key Considerations
- Patients with chronic kidney disease taking AV nodal blocking medications are particularly susceptible to BRASH syndrome 2, 3, 4
- The prognosis of BRASH syndrome is excellent with timely recognition and management 1, 5
- A medication review, particularly of cardiac medications, including AV nodal blocking agents, is critical for diagnosing BRASH syndrome 1
- The management principles of BRASH syndrome are conservative management, addressing the precipitating event or medications, and correcting electrolyte derangements 1
Treatment Approach
- Initial management: calcium gluconate, insulin, and sodium bicarbonate to stabilize cardiac membranes and shift potassium intracellularly
- Diuretics or dialysis for potassium removal
- Vasopressors like norepinephrine for hypotension
- Temporary cardiac pacing for severe bradycardia
- Addressing underlying causes and adjusting medications to prevent recurrence 2, 3, 4, 1, 5