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

A 59-year-old female with past medical history of hypertension, type 2 diabetes mellitus, end-stage renal disease (ESRD) on hemodialysis (HD) presented to the emergency department (ED) with a request for routine HD (note: Cook County Hospital has a cohort of patients who routinely receive their HD via the emergency department rather than through an outpatient clinic). Initial vital signs were notable for hypertension but were otherwise unremarkable. The patient denied any symptoms, but reported that her last HD session was more than a week ago. The Renal service was consulted for HD and recommended obtaining labs given her missed HD sessions. The potassium level returned at 8.7 (not hemolyzed).

Alexandra Atkins, MD and Ari Edelheit, MD

the County Consult