BRASH Syndrome Leading to Cardiac Arrest and Diffuse Anoxic Brain Injury: An Underdiagnosed Entity

Abstract

BRASH (bradycardia, renal failure, atrioventricular [AV] nodal blocking medications, shock, hyperkalemia) syndrome describes the phenomenon of profound bradycardia from a combination of hyperkalemia and use of AV nodal blocking medication with underlying renal injury. We present a case of BRASH syndrome in a patient on chronic beta-blocker therapy for his coronary artery disease who presented with life-threatening hyperkalemia and acute renal failure. Due to failure in early recognition and superimposed effect with further beta-blocker dosing, the patient developed profound bradycardia and later went into pulseless electrical activity cardiac arrest requiring cardiopulmonary resuscitation. Metabolic derangements and bradycardia later resolved with medical management, but unfortunately, the patient developed diffuse anoxic brain injury after the cardiac arrest and was declared brain dead.

Keywords: av nodal blocking medications; bradycardia; brash; cardiac arrest; ecg (electrocardiogram); hyperkalemia; renal failure.

Figure 1. ECG shows sinus bradycardia with first-degree atrioventricular block

Figure 2. Axial CT scan of the head shows complete loss of gray-white matter differentiation and complete obliteration of brain sulci and cisterns suggesting diffuse anoxic brain injury

CT, computerized tomography

Figure 3. Reconstructed image of the CTA head and neck shows complete occlusion of bilateral vertebral arteries (red arrows) and complete occlusion of bilateral internal carotid arteries (yellow arrows) along with lack of intracranial circulation (green arrows)

CTA, computerized tomography angiography