Abstract Introduction: • BRASH syndrome—Bradycardia, Renal failure, AV nodal blocker use, Shock, and Hyperkalemia—is an emerging clinical entity characterized by a synergistic interaction between bradycardia, acute renal failure, hyperkalemia, and the use of AV nodal blocking agents like beta-blockers or calcium channel blockers.• We present the case of a 54-year-old male with chronic kidney disease and hypertension who developed BRASH syndrome, resulting in multi-organ dysfunction and necessitating emergent intervention. Case: • A 54-year-old male with chronic alcoholism, cirrhosis, atrial fibrillation, coronary artery disease, hypertension, hyperlipidemia, uncontrolled diabetes, anemia, and smoking presented with acute shortness of breath. • He arrived lethargic, hypoxic on 2L oxygen, bradycardic (HR in 30s), and hypotensive. Initial labs showed sodium 118 mmol/L, potassium 6.5 mmol/L, and creatinine 3.47 mg/dL. Multiple prescription bottles of diltiazem and metoprolol were found, raising suspicion of overdose.• He was started on dopamine and treated with calcium gluconate, insulin, dextrose, and albuterol for hyperkalemia. Glucagon was trialed with limited response, followed by an insulin drip for suspected calcium channel blocker toxicity.• Unfortunately, the patient's condition deteriorated with worsening hypoxia and poor GCS, requiring intubation. Repeat labs showed severe metabolic acidosis (pH 7.00, HCO39.4), potassium 6.6 mmol/L, creatinine 3.86 mg/dL, and lactate >12 mmol/L. • Bedside echocardiogram indicated poor cardiac contractility. A diagnosis of cardiogenic shock was made and patient was started on multiple pressors with insulin gradually increased to 4.5 U/kg/hr.• A trialysis catheter was then placed, and CRRT was initiated. Within the next few hours, patient made remarkable recovery with resolution of lactic acidosis. He was extubated and transferred out of ICU on the same day. Discussion:• BRASH syndrome is increasingly recognized in emergency and critical care settings. • The syndrome arises from an interplay between hyperkalemia and AV-nodal-blockers, leading to severe bradycardia. The bradycardia reduces cardiac output, worsening renal perfusion and exacerbating renal failure and hyperkalemia in a dangerous cycle.• It is most common in elderly patients with heart disease and renal dysfunction on antihypertensives, especially those managing atrial fibrillation with multiple AV-nodal blockers.• Management typically involves medical therapy, with renal replacement therapy required in 20% of cases, and pacing in 33%. Mortality is estimated at 5.7%.• This case highlights the importance of recognizing and interrupting the BRASH cycle early to prevent progression to multi-organ failure. Conclusion:BRASH syndrome is a potentially fatal interaction of bradycardia, renal failure, hyperkalemia, and AV-nodal blocker use, requiring timely intervention.
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