Identification and Management of BRASH Syndrome in the ER-Identification and Management of BRASH Syndrome in the ER

Video Transcription

Video Summary

This presentation by Jake Miller, a nurse practitioner and critical care transport clinician, introduces Brash syndrome—a recently defined clinical syndrome characterized by bradycardia, renal failure, AV nodal blockade, shock, and hyperkalemia. First formally described less than a decade ago by Dr. Josh Farkas, Brash syndrome represents a synergistic interplay of these factors rather than any single element alone. The syndrome often presents in patients on AV nodal blocking agents (e.g., beta blockers or calcium channel blockers) who develop acute kidney injury and hyperkalemia, resulting in profound bradycardia and shock. Hypovolemia, such as from diabetic ketoacidosis-induced dehydration, commonly precipitates it. Management requires addressing all components simultaneously—fluid resuscitation with balanced solutions, calcium administration to stabilize cardiac membranes and reverse AV blockade, insulin to reduce serum potassium, and vasopressors (like epinephrine) to support heart rate and blood pressure. Pacing may be necessary initially but often is temporary. Recognizing Brash syndrome is critical because its elements amplify one another, and treating only one piece may fail. Providers are encouraged to consider this syndrome in emergency and transport settings when encountering bradycardia with renal dysfunction and hyperkalemia in patients on nodal blockers. Resources for further learning include free open-access medical education sites and publications by Dr. Farkas.

Keywords

Brash syndrome

bradycardia

renal failure

AV nodal blockade

hyperkalemia

beta blockers

critical care transport