An Enigma of Emerging Emergency-BRASH SYNDROME: A Retrospective Case Series

A BSTRACT Background: The BRASH (bradycardia, renal failure, AV nodal blockade, shock, and hyperkalemia) syndrome is a synergy between hyperkalemia and AV nodal blockers, leading to bradycardia. Though treatment is mainly supportive care, understanding the pathophysiology and correcting the precipitating causes will help prevent the patient from progressing to a catastrophic outcome. Materials and Methods: This was a retrospective study conducted in the emergency department of a tertiary care hospital. Medical records of cases admitted from the emergency medicine department from January 2021 to July 2022 with bradycardia and hyperkalemia were retrieved from hospital software systems. Data regarding presenting symptoms, vitals, laboratory and radiological investigations, and treatment received were noted, and the data was analyzed. Results: This study includes a total of seven cases that fit the definition of BRASH syndrome. The majority were elderly co-morbid patients with a median age of 53 (49-79) years, on anti-hypertensives, with varied presentations. They had mild to moderate hyperkalemia, with a mean value of 7.15 ± 2.31 mEq/L. Acute kidney injury was evident, with a mean creatinine value of 3.55 mg/dl. Initial ECG revealed bradyarrhythmias, with five junctional bradycardias and two sinus bradycardias. Among the seven cases, three were managed conservatively, three were dialyzed, and one underwent transvenous pacing. Six cases recovered and discharged home, with one mortality. Conclusion: BRASH syndrome is an under-recognized entity. Early recognition and treatment can avoid invasive procedures like pacing and dialysis and also prevent morbidity and mortality.