BRASH syndrome

Question 1

What does BRASH syndrome stand for?

Answer 1

B - Bradycardia
R - Renal failure (acute, chronic, acute on chronic)
A - AV nodal blocking medication (on one)
S - Shock
H - hyperkalaemia

Question 2

Which patient group does BRASH classically in?

Answer 2

Elderly patients with +/- coexisting heart disease and renal failure who are taking an AV nodal blocking drug

Question 3

What drugs can be implicated in BRASH?

Answer 3

Beta-blockers
CCB

ACE-inhibitors can worsen the renal failure and hyperkalaemia but the primary drugs are above

Question 4

Why does BRASH occur?

Answer 4

The renal failure either acute or chronic worsening causes increasing serum levels of renally excreted AV nodal blocking drugs leading to toxic levels

Question 5

What is the treament of BRASH?

Answer 5

IV calcium gluconate 10mmol IV
Atropine 400mcg PRN up to 2mg for bradycardic shock
IV fluid replacement (judicious in heart failure)
Consider sodium bicarbonate (See below)
Insulin + dextrose: 10 units actrapid 50mls of 50% dextrose
CRRT versus dialysis (if already a dialysis patient)
Stop offending agent then dose reduction or change

IV fluid therapy (judicious in heart failure)
A patient with BRASH syndrome will usually be volume deplete, a good choice of fluid is ‘normal’ bicarb; made by adding 150mls of 8.4% Sodium Bicarbonate to 850mls of water for injection, giving 1L of isotonic fluidCalcium - membrane stabilisation

Question 6

What is the differential of symptomatic bradycardia?

Answer 6

Cardiac:
* Inferior MI - CHB
* Sick sinus syndrome
* Hypersensitive carotid sinus syndrome

Neurogenic:
* Coning
* SAH

Electrolyte abnormalities:
* Hyperkalaemia particularly

Endo:
* Hypothyroidism myxoedema
* Hypoglycaemia

Drugs:
* Digoxin
* Clonidine
* Beta blocker
* CCB
* Opiates

High level fitness

Many causes!