Brash syndrome: Difference between revisions
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==Background== | ==Background== | ||
*Combination of | [[File:Brash syndrome.png|thumb|via emcrit.org]] | ||
**Bradycardia | *Combination of: | ||
**Renal failure | **[[Bradycardia]] | ||
**AV node blocker: beta-blocker, verapamil or diltiazem | **[[Renal failure]] | ||
**Shock | **AV node blocker: [[beta-blocker]], [[verapamil]] or [[diltiazem]]- typically adherent with medication but an overdose | ||
**Hyperkalemia | **[[Shock]] | ||
*Vicious cycle in setting of medications, hyperkalemia, renal failure | **[[Hyperkalemia]] | ||
*Renal failure causes hyperkalemia | *Vicious cycle: in setting of medications, hyperkalemia, renal failure | ||
*Often initiated by an episode of hypovolemia, hypoperfusion, or uptitration of antihypertensives or K sparing diuretics | |||
*Renal failure causes hyperkalemia (+/- accumulation of AV node blockers), hyperkalemia synergizes with AV node blockers to cause bradycardia and hypoperfusion, hypoperfusion worsens renal failure <ref> Hegazi MO, et al. Junctional bradycardia with verapamil in renal failure--care required even with mild hyperkalemia. J Clin PHarm Ther. 2012;37(6):726-8. </ref> | |||
==Clinical Features== | ==Clinical Features== | ||
* | *Asymptomatic or symptomatic [[bradycardia]] | ||
* | **Typically appear more well than vitals/labs suggest | ||
*Altered mental status | *Multisystem organ failure ([[shock]], [[pulmonary edema]], [[renal failure]], shock liver) | ||
*[[Altered mental status]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Symptomatic bradycardia}} | |||
==Evaluation== | ==Evaluation== | ||
* | *May have only mild hyperkalemia, with bradycardia out of proportion to degree of hyperK | ||
* | *[[EKG]]: may mot have typical findings of hyperkalemia | ||
==Management== | ==Management== | ||
*[[Hyperkalemia]] treatment (e.g. IV [[insulin]]/[[dextrose]], [[albuterol]], IV calcium, kaliuresis or dialysis) | |||
*[[IVF]] resuscitation for hypovolemia | |||
*Catecholamines (e.g. [[epinepherine]]) for persistent bradycardia/shock | |||
*Consider [[isoproterenol]] | |||
*Targeted treatments for beta-blocker or CCB overdose not helpful | |||
*May not respond well to [[atropine]] or transcutaneous pacing | |||
*Aggressive early diuresis | |||
==Disposition== | ==Disposition== | ||
*Admit, typically to ICU setting | |||
==See Also== | ==See Also== | ||
*[[Renal failure]] | |||
*Pure [[hyperkalemia]] | |||
*Pure AV node blocker intoxication (e.g. [[calcium channel blocker toxicity]], [[beta-blocker toxicity]]) | |||
==External Links== | ==External Links== | ||
*[https://emcrit.org/pulmcrit/brash-syndrome-bradycardia-renal-failure-av-blocker-shock-hyperkalemia/ EMCrit - BRASH Syndrome: Bradycardia, Renal Failure, AV Blocker, Shock, Hyperkalemia] | |||
*[https://litfl.com/brash-syndrome/ LITFL - BRASH Syndrome] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Critical Care]] [[Category:FEN]] [[Category:Cardiology]] | |||
Latest revision as of 02:41, 1 July 2021
Background
- Combination of:
- Bradycardia
- Renal failure
- AV node blocker: beta-blocker, verapamil or diltiazem- typically adherent with medication but an overdose
- Shock
- Hyperkalemia
- Vicious cycle: in setting of medications, hyperkalemia, renal failure
- Often initiated by an episode of hypovolemia, hypoperfusion, or uptitration of antihypertensives or K sparing diuretics
- Renal failure causes hyperkalemia (+/- accumulation of AV node blockers), hyperkalemia synergizes with AV node blockers to cause bradycardia and hypoperfusion, hypoperfusion worsens renal failure [1]
Clinical Features
- Asymptomatic or symptomatic bradycardia
- Typically appear more well than vitals/labs suggest
- Multisystem organ failure (shock, pulmonary edema, renal failure, shock liver)
- Altered mental status
Differential Diagnosis
Symptomatic bradycardia
- Cardiac
- Inferior MI (involving RCA)
- Sick sinus syndrome
- Neurocardiogenic/reflex-mediated
- Increased ICP
- Vasovagal reflex
- Hypersensitive carotid sinus syndrome
- Intra-abdominal hemorrhage (i.e. ruptured ectopic)
- Metabolic/endocrine/environmental
- Hyperkalemia
- Hypothermia (Osborn waves on ECG)
- Hypothyroidism
- Hypoglycemia (neonates)
- Toxicologic
- Infectious/Postinfectious
- Other
Evaluation
- May have only mild hyperkalemia, with bradycardia out of proportion to degree of hyperK
- EKG: may mot have typical findings of hyperkalemia
Management
- Hyperkalemia treatment (e.g. IV insulin/dextrose, albuterol, IV calcium, kaliuresis or dialysis)
- IVF resuscitation for hypovolemia
- Catecholamines (e.g. epinepherine) for persistent bradycardia/shock
- Consider isoproterenol
- Targeted treatments for beta-blocker or CCB overdose not helpful
- May not respond well to atropine or transcutaneous pacing
- Aggressive early diuresis
Disposition
- Admit, typically to ICU setting
See Also
- Renal failure
- Pure hyperkalemia
- Pure AV node blocker intoxication (e.g. calcium channel blocker toxicity, beta-blocker toxicity)
External Links
- EMCrit - BRASH Syndrome: Bradycardia, Renal Failure, AV Blocker, Shock, Hyperkalemia
- LITFL - BRASH Syndrome
References
- ↑ Hegazi MO, et al. Junctional bradycardia with verapamil in renal failure--care required even with mild hyperkalemia. J Clin PHarm Ther. 2012;37(6):726-8.