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    BRASH Syndrome – Diagnosis and Treatment

    Cardiovascular, Critical Care / Resuscitation

    Last Updated Feb 17, 2022
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    By Julian Marsden, Kevin Choi


    • 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.

    Diagnostic Process

    • 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.

    Recommended Treatment

    • 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?


    The literature on BRASH syndrome is sparse and consists of a few case reports. Treatment suggestions are based on case reports and expert opinion.


    Related Information

    Reference List

    1. 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.

    2. 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.

    3. 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.

    4. Further readings

      BRASH syndrome


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