Infographics: B.R.A.S.H Syndrome


B.R.A.S.H Syndrome

Bradycardia, Renal Failure, AV Nodal Blockade, Shock, and Hyperkalemia

This infographic provides a comprehensive look at B.R.A.S.H syndrome, a critical condition resulting from the interaction of AV nodal blockade, hyperkalemia, and renal failure, leading to bradycardia and shock.

Differential Diagnosis

  • B.R.A.S.H results from the combined effects of AV nodal blockers and renal failure, contributing to hyperkalemia and bradycardia.
  • Hyperkalemia can independently cause bradycardia; ECG findings typically show peaked T waves and flattened P waves.
  • AV Nodal Blocker Toxicity may also mimic B.R.A.S.H, often triggered by infections, new medications, or electrolyte imbalances.

Etiology

  • Contributing factors include medications like beta-blockers, calcium-channel blockers, ACE inhibitors, and diuretics.
  • Renal failure leads to reduced excretion of medications and potassium, exacerbating the condition.

Pathophysiology

  • Reduced renal function impairs the clearance of AV nodal blockers, causing bradycardia and worsening hyperkalemia.
  • This creates a vicious cycle, with shock lowering cardiac output (CO) and renal blood flow, further decreasing GFR and increasing potassium levels.

Presentation

  • Patients often present with bradycardia, recent GI illness, dehydration, and multiorgan failure.
  • ECG changes include peaked T waves and prolonged PR intervals.

Management Considerations

  • Hyperkalemia: Treat with IV calcium, albuterol, insulin, and dextrose to promote intracellular potassium shift.
  • Bradycardia and Hypotension: Use epinephrine or isoproterenol; consider temporary pacing if needed.
  • Hemodialysis: Indicated in severe cases of hyperkalemia.
  • Fluid resuscitation: Use balanced crystalloids if non-anion gap metabolic acidosis is absent.
  • For beta-blocker toxicity, consider lipid emulsion therapy; administer digoxin-specific antibody fragments in cases of digoxin toxicity.

Created by Dr. Chelsea Amo-Tweneboah
Reviewed by Dr. Rawan Amir and Dr. Jessie Holtzman


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