Bradycardia and cardiogenic shock with suspicion of BRASH

syndrome in patient with chronic kidney disease: a case report

M.A. Ansori1, R. Fadhilah1, H. Hernawan2, 1General Practitioner, Dinda General Hospital,

Tangerang, Banten; Indonesia; 2Cardiologist, Dinda General Hospital, Tangerang, Banten

Abstract

Background: BRASH syndrome is a syndrome characterized by bradycardia, renal failure, use

of atrioventricular nodal blocker (AVNB) drugs, shock, and hyperkalemia. Until now, BRASH

syndrome has not been classified as a single disease so that research on its epidemiology is still

limited in the form of case reports.

Case Summary: In this case report, a 58-year-old man with a history of chronic kidney disease

and routine hemodialysis comes to the ED with complaints of vomiting and weakness. Based on

the physical examination, ECG, and initial lab results the patient was diagnosed with bradycardia,

cardiogenic shock, and hyperkalemia. From the additional history, it is suspected that the patient

is taking AVNB drugs. The patient was initially treated with a bradycardia algorithm but did not

show clinical improvement. Clinical improvement began to appear after the patient was given

correction of hyperkalemia with insulin-glucose and hemodialysis and management of

cardiogenic shock.

Discussion: The patient is suspected of having BRASH syndrome. The standard ACLS algorithm

will fail to optimally manage bradycardia in BRASH syndrome. The key to the management of

BRASH syndrome is to treat all components simultaneously.

Keywords: bradycardia, hyperkalemia, kidney disease, shock