BRASH Syndrome in the Emergency Department: Diagnostic and Therapeutic Insights from a Case Series

Introduction: In the emergency department, overdose is typically followed by beta-blocker toxicity. BRASH syndrome (bradycardia, renal failure, AV-nodal blockade, shock, and hyperkalemia) is an increasingly recognized iatrogenic emergency in which profound hemodynamic collapse occurs at therapeutic drug doses. The optimal timing and role of renal replacement therapy (RRT) remain unclear. Case Series: We describe four elderly patients with atenolol-precipitated BRASH syndrome presenting with profound sinus bradycardia, circulatory shock, acute kidney injury, and moderate hyperkalemia. All were initially managed per the ACLS bradycardia algorithm; atropine, calcium, and insulin–dextrose therapy failed to produce sustained hemodynamic recovery. Urgent hemodialysis in all four patients resulted in rapid restoration of intrinsic heart rate, reversal of shock, and weaning of vasopressor/adrenaline support within hours. Conclusion: Resistance to ACLS-standard interventions in the context of renal impairment and AV-nodal-blocker use should prompt early consideration of hemodialysis as a primary hemodynamic intervention, rather than a late metabolic rescue, in atenolol-induced BRASH syndrome.