A Cook County Hospital Emergency Medicine Blog for up-to-date medicine and more.
Figure 1. Initial arrhythmia detected on telemetry
A 74 year old male with history of STEMI s/p PCI with DES of LAD and RI, HFrEF (EF 20-25%), sick sinus syndrome s/p DC-PPM, atrial flutter, hypertension, insulin-dependent diabetes, severe PAD s/p right IR SFA stent, and pancreatic insufficiency presenting for hypotension from general surgery clinic. The patient is brought to the resuscitation bay and while you are waiting for your work-up the monitor alarms and shows the following (Figure 1).
Michael Hohl MD and Ari Edelheit MD
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We start this lovely Wednesday with EMS bringing in a 70-year-old man who just had a v-fib/v-tach arrest. After 5 rounds of CPR, 4 shocks, and 3 doses of epi, they’ve got him back! You prep airway equipment and the ultrasound, and in a few minutes, the patient arrives.
Samson Frendo MD and Eric Leser MD
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Figure 1. BRASH Syndrome feedback loop (Source: https://litfl.com/brash-syndrome/)
It’s 3 a.m. on an overnight shift and the resuscitation room nurse runs over, “Hey doc, the patient in R3 is bradycardic and now his blood pressure is dropping”. You rush in, begin thinking through which medications to give and place pads on the patient. Luckily, he begins to stabilize with vasopressors and pacing. You review his labs again; he has worsening renal function and he’s mildly hyperkalemic to 5.7. He has metoprolol on his medication list but denies taking more than prescribed. So what’s actually going on?
Today we will discuss BRASH syndrome, which stands for Bradycardia, Renal failure, AV Blockade, Shock and Hyperkalemia.
Kathryn McGregor, MD and Eric Leser, MD
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