History

• 69 yo M hx of HTN on unknown medications presents to the ED with complaints of chest pain and weakness which began ~1 hr prior
• Pain is substernal, nonradiating, without associated dyspnea, nausea, diaphoresis
• No recent illnesses, no fevers/vomiting/diarrhea/abdominal pain/cough
• Pt denies hx of CAD or MI
• ALS found pt with a HR of 30, with BP 100 systolic, awake and alert

ROS

• Positive for chest pain, weakness otherwise unremarkable

PMHx

• Hypertension compliant with unknown medications
• Type II DM on unknown oral medication

Physical Exam

BP 92/41  HR 42  T 97.7 RR 20 Pox 98% on RA

• Pt awake and alert, conversant
• Lungs clear
• Heart: bradycardic, no murmurs
• Abd: soft NTND
• Extrem: no edema, pulses intact
• Neuro: GCS 15, nonfocal exam

ECG:

ECG interpretation: Sinus bradycardia, Left Bundle Branch Block pattern, Sgarbossa criteria negative

FSBS: 379

DDx for Bradycardia/Hypotension

• Quick review of many potential causes here

Abbreviated Ddx:

• Acute Cardiac Ischemia
• Medication overdose (beta blockers, calcium channel blocks, digoxin, clonidine)
• Hyperkalemia

Management

• Transcutaneous pacer pads placed on patient
• Atropine 1 mg given with no response
• IVF bolus 500 ml, BP --> 100 systolic
• Cardiology consult placed with concerns for acute ischemia given complaints of ongoing chest pain, possible new left bundle branch block in setting of bradycardia

Clinical Course

• 40 minutes after arrival pt had an brady-asystolic cardiac arrest
• Chest compressions started immedialy
• Pt treated with 1 mg epinephrine and 1g calcium gluconate
• ROSC achieved within 3 minutes of arrest, pt again awake and alert
• Lab contacted urgently and confirmed potassium of 7.7 along with Cr 3.7 (unknown baseline)

Diagnosis and Case Resolution

• Patient ultimately diagnosed with BRASH syndrome, a constellation of findings including: Bradcyardia, Renal failure, AV nodal blocking agents (beta blocker in this case), Shock, and Hyperkalemia
• Check out this excellent summary of BRASH syndrome from the Journal of Emergency Medicine here
• Pt was treated with IV calcium chloride, albuterol 10 mg by nebulization, insulin 10 units IV
• A norepinephrine and subsequent dopamine infusion were started to support HR and BP
• A foley catheter was placed with 100 ml clear yellow urine
• Nephrology recommended lasix 100 mg IV and monitoring of UOP response
• Pt maintained good UOP and followup potassium was 5.5
• Pt creatinine and potassium continued to improve and he did not ultimately require emergent hemodialysis
• Pt was discharged in good condition 2 days later

Take Home Points

• Hyperkalemia is a common cause of bradycardia
• Unstable patients should be treated empirically with IV calcium while waiting for lab confirmation
• A VBG with lytes may provide a faster laboratory confirmation, though the specimen may have unrecognized hemolysis
• The combination of acute renal failure (sometimes from vomiting/diarrhea) in conjunction with AV nodal blocking agents may result in BRASH syndome
• Acute treatment is aimed as for management of hyperkalemia and emergency hemodialysis may be required if patient is anuric or unresponsive to treatment

Sources:

Farkas, Joshua et al. BRASH Syndrome: Bradycardia, Renal Failure, AV Blockade, Shock, and Hyperkalemia. Journal of Emergency Medicine 59 (2); 216-223.