A Case of BRASH Syndrome in an Elderly Female With Acute Urinary Retention

The BRASH syndrome is an uncommon but serious medical condition that is distinguished by a confluence of symptoms that include bradycardia, renal failure, AV node dysfunction, shock, and hyperkalemia. Bradycardia associated with BRASH syndrome is often refractory to conventional management guided by advanced cardiac life support (ACLS), therefore prompt and appropriate intervention can only be administered in the setting of early recognition. The management of BRASH syndrome in elderly patients can prove to be particularly challenging, primarily because of pre-existing comorbidities that place these patients at increased risk of complications. We present the case of an 82-year-old female who presented to the emergency department with acute urinary retention. Initial laboratory evaluation revealed severe hyperkalemia and acute kidney injury. Her EKG showed bradycardia with a junctional rhythm. Medication reconciliation revealed multiple potassium-sparing and AV nodal-blocking agents. The patient's presentation was consistent with the BRASH syndrome and the patient was treated with potassium lowering and vasoactive agents. Her bradycardia resolved upon treatment of hyperkalemia. Her admission was complicated by renal replacement therapy given the degree of renal dysfunction however the patient was ultimately discharged after renal function improved. Upon discharge, the suspected precipitants of BRASH syndrome including beta blockers, mineralocorticoid receptor antagonists, and angiotensin receptor antagonists were all discontinued.