Pavlatos NT, Daga P, Smiley Z, Belur A, Bhattacharya P, Khan R. Critical presentation of bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia syndrome: A case report. World J Clin Cases 2025; 13(25): 107948 [DOI: 10.12998/wjcc.v13.i25.107948]
Corresponding Author of This Article
Nicholas Thales Pavlatos, MD, Internal Medicine, University of Louisville, 550 South Jackson Street 3rd Floor, Ste. A3K00, Louisville, KY 40204, United States. ntpavl01@louisville.edu
Research Domain of This Article
Critical Care Medicine
Article-Type of This Article
Case Report
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Nicholas Thales Pavlatos, Pawan Daga, Zyad Smiley, Department of Internal Medicine, University of Louisville, Louisville, KY 40204, United States
Agastya Belur, Priyanka Bhattacharya, Rafay Khan, Department of Cardiovascular Medicine, University of Louisville, Louisville, KY 40204, United States
Author contributions: Pavlatos NT, Smiley Z, Bhattacharya P draft preparation and figure preparation; Daga P, Belur A, Khan K draft manuscript preparation and figure preparation. All authors have read and agreed to the published version of the manuscript.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: We have no conflicts of interest to disclose. All authors declare that they have no conflicts of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Nicholas Thales Pavlatos, MD, Internal Medicine, University of Louisville, 550 South Jackson Street 3rd Floor, Ste. A3K00, Louisville, KY 40204, United States. ntpavl01@louisville.edu
Received: April 1, 2025 Revised: April 22, 2025 Accepted: May 18, 2025 Published online: September 6, 2025 Processing time: 97 Days and 9.4 Hours
Abstract
BACKGROUND
Bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia (BRASH) syndrome is an acronym used to describe a constellation of BRASH. It is an underrecognized phenomenon that can be deadly if not appropriately managed in a timely manner. This case highlights the importance of rapid diagnosis and reviews a multitude of treatment options in a uniquely severe case of BRASH syndrome.
CASE SUMMARY
We present a case of a 54-year-old male on a beta-blocker and angiotensin-converting enzyme inhibitor who presented with one day history of nausea, vomiting, and shortness of breath. Upon presentation, he was bradycardic and hypotensive, requiring transcutaneous pacing. Initial electrocardiogram showed atrial fibrillation with ventricular rate in 30’s. He was found to have acute kidney injury, hyperkalemia, and metabolic acidosis. He was successfully treated with multiple potassium lowering agents, continuous renal replacement therapy, four pressors, mechanical ventilation, and transvenous pacing with complete recovery prior to discharge.
CONCLUSION
Increased awareness of BRASH syndrome may improve outcomes through timely diagnosis and aggressive intervention.
Core Tip: Bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia (BRASH) syndrome is an acronym used to describe a constellation of BRASH. Effective management of BRASH syndrome often requires a multidisciplinary approach within the intensive care unit and consists of cessation of offending agents, potassium lowering measures, renal replacement therapy, hemodynamic pressor support, and/or cardiac pacing.
