All About BRASH!

BRASH (bradycardia, renal failure, atrio-ventricular nodal blocking agents, shock and hyperkalemia) Syndrome, a medical entity which has been described more recently, continues to be under-diagnosed. These manifestations do not occur in isolation but are inter-linked with synergistic effects on a susceptible patient. Being aware and having a high index of suspicion of the whole spectrum is important, just as managing all its components simultaneously for the desired outcomes. However, its variable presentation proves to be both a diagnostic and therapeutic clinical challenge. Hypovolemia and antihypertensive medications are the most common triggering factors for BRASH Syndrome. These factors may lead to pre-renal injury and hyperkalemia and when coupled with the AV blockers, can lead to the BRASH Syndrome cascade. In addition, the progression of renal failure can potentiate hyperkalemia and bradycardia from AV blockade. Electrocardiographical(ECG) changes can range from junctional bradycardia, heart blocks and classical changes of hyperkalemia.

BRASH Syndrome has been noted to have life threatening consequences if the vicious cannot be halted and the patient is not responsive to therapy.

Understanding the pathophysiology, having a high index of suspicion and commencing simultaneous management for all its components is critical.

As BRASH Syndrome is relatively newly described and the literature continues to evolve around the topic we have decided to review the topic, collating findings from published case reports , to tap on the rich observations and findings reported by the authors. These, we find, can be extremely valuable, as we negotiate this exciting syndrome and learn more about it, from the scientific and clinical community.

Keywords: BRASH, bradycardia, renal failure, shock, hyperkalemia, beta-blockers, calcium channel blockers.