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Case report
BRASH syndrome
  1. Shaurya Srivastava1,
  2. Tyler Kemnic2,3 and
  3. Kyle R Hildebrandt2
  1. 1College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
  2. 2Department of Medicine, Michigan State University, East Lansing, Michigan, USA
  3. 3Sparrow Hospital, Lansing, Michigan, USA
  1. Correspondence to Dr Tyler Kemnic; kemnicty{at}


A 62-year-old woman with chronic kidney disease stage 4, sleep apnoea on continuous positive airway pressure and recent admission for acute-on-chronic diastolic heart failure presented to emergency room with weakness. She was hypotensive and had symptomatic bradycardia in the 30 s secondary to hyperkalaemia and beta-blockers, raising concern for BRASH syndrome. Antihypertensives were immediately held. Potassium-lowering agents (with calcium gluconate for cardiac stability) were begun, as were fluids and dopamine for vasopressor support. The patient was admitted to intensive care unit and electrophysiology was consulted. Over the next 2 days, the patient clinically improved: she remained off dopamine for over 24 hours; potassium levels and renal function improved; and heart rate stabilised in 60 s. The patient was eventually discharged and advised to avoid metolazone, bumetanide and carvedilol, with primary care provider and cardiology follow-up.

  • adult intensive care
  • fluid electrolyte and acid-base disturbances
  • pacing and electrophysiology
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  • Contributors SS: wrote the case summary and presentation, assisted in literature review, completed works cited and edited the final draft. TK: obtained consent; wrote the background/differential treatment/outcome, assisted in literature review and works cited, edited final draft. KH: wrote the discussion, assisted in the literature review and edited the final draft.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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