Bradycardia is a condition where the patient is having a low heart rate. It is defined as resting heart rate of 60 beats per minute or less.The presentation of bradycardia can vary widely from asymptomatic bradycardia to haemodynamically unstable which can lead to shock. In BRASH syndrome, patient presented with following criterias which are Bradycardia, Renal failure, AV node blockers, Shock, and Hyperkalaemia.
A 67 year old gentleman with underlying diabetes mellitus and hypertension on beta blocker presented with sudden generalized body weakness, reduced oral intake, less responsive, sweating which resolved with sweet drink. He however denied any fever, upper respiratory tract infection symptoms, chest pain, shortness of breath, palpitation or abdominal pain.Patient was alert with GCS 15/15, pink conjunctiva,capillary refilling about 2 sec, however looked dehydrated with weak pulse volume. His blood pressure was 85/32mmHg with bradycardia which was 32 beat per minutes. His capillary blood sugar was 22 mmol/L. Lungs, cardiovascular, abdominal and neurovascular examination was normal. His urine output was nil. His renal profile come back with urea 14.6 mmol/L,sodium 129.5 mmol/L, potassium 5.9 mmol/L,chloride 99.2 mmol/L and creatinine 404 umol/L.The final diagnosis is junctional heart block with hyperkalaemia and patient was admitted to ICU.
DISCUSSION AND CONCLUSION
BRASH syndrome refers to a vicious cycle which may occur when a patient taking AV node blockers develops renal failure and hyperkalemia. This leads to worsening hyperkalemia, renal failure, bradycardia, hypoperfusion and shock. It is usually seen in elderly patient with cardiac disease and renal insufficiency that is on treatment of AV node blockers. The treatment of BRASH syndrome mainly focusing on treatment for hyperkalemia.Clinical suspicion of hyperkalaemia should be made from the history and physical examination. Life threatening hyperkalaemia may cause profound bradycardia. Therefore treatment could be given early while awaiting for the result.
BRADYCARDIA, HYPERKALAEMIA, ELDERLY, DEHYDRATION, AV NODE BLOCKER