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BRASH现象:一例关于心动过缓、急性肾衰竭、房室结阻滞、休克和高钾血症危险组合的病例报告

BRASH Phenomenon: A Case Report on the Dangerous Combination of Bradycardia, Acute Renal Failure, Atrioventricular Nodal Blockade, Shock, and Hyperkalemia.

作者信息

Okan Tetyana, Arastu Azeem, Zarghami Mehrdad, Patel Vidhi, Chinakwe Uchenna, Lasic Zoran

机构信息

Internal Medicine, Jamaica Hospital Medical Center, New York, USA.

Cardiology, Lenox Hill Hospital, New York, USA.

出版信息

Cureus. 2025 Aug 24;17(8):e90898. doi: 10.7759/cureus.90898. eCollection 2025 Aug.

DOI:10.7759/cureus.90898
PMID:40995280
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC12456856/
Abstract

Bradycardia, renal failure, AV nodal blockade, shock, and hyperkalemia (BRASH) syndrome is a rare medical phenomenon that includes the aforementioned symptoms. It can lead to multisystem organ failure, resulting in high mortality. We are reporting a case of BRASH syndrome in a 70-year-old female with a history of chronic kidney disease, severe rheumatic mitral stenosis and paroxysmal atrial fibrillation who presented to the emergency department after an episode of presyncope and worsening shortness of breath. The patient's home medications included carvedilol and apixaban (due to non-compliance with warfarin). Her initial blood pressure (BP) was 162/99 mmHg and heart rate (HR) 28 beats/min. EKG showed junctional bradycardia. After administration of atropine for symptomatic bradycardia and glucagon to reverse beta-blocker activity given poor response to initial atropine treatment, there was a transient improvement of HR to 43 beats/min. However, her BP decreased to 70/40 mmHg, requiring dopamine infusion. Laboratory findings showed significantly elevated blood urea nitrogen (BUN) at 114 mg/dL, creatinine at 12.4 mg/dL (baseline creatinine 6 mg/dL), and critical hyperkalemia of 7.9 mEq/L. These results prompted immediate treatment with intravenous calcium gluconate and an insulin-dextrose infusion, along with oral sodium zirconium cyclosilicate and albuterol nebulization. The patient was admitted to the intensive care unit for management of cardiogenic shock with refractory bradycardia and acute kidney injury with severe hyperkalemia requiring hemodialysis.  She underwent urgent hemodialysis with resolution of hyperkalemia and improvement of HR to 68 beats/min and rhythm to sinus, thus, there was no need for pacemaker placement. She was discharged home with initiation of outpatient dialysis.  Early recognition of BRASH syndrome is crucial because its management differs significantly from the standard Advanced Cardiovascular Life Support (ACLS) bradycardia algorithm. Unlike the standard approach, therapy for BRASH syndrome extends beyond atropine and electrolyte correction to potentially include hemodynamic vasopressor support, temporary transcutaneous pacing, and urgent renal replacement therapy.

摘要

缓慢性心律失常、肾衰竭、房室结阻滞、休克和高钾血症(BRASH)综合征是一种罕见的医学现象,包括上述症状。它可导致多系统器官衰竭,死亡率很高。我们报告一例70岁女性的BRASH综合征病例,该患者有慢性肾脏病、严重风湿性二尖瓣狭窄和阵发性心房颤动病史,在一次晕厥前发作和气短加重后就诊于急诊科。患者的家庭用药包括卡维地洛和阿哌沙班(因未遵医嘱服用华法林)。她的初始血压(BP)为162/99 mmHg,心率(HR)为28次/分钟。心电图显示交界性心动过缓。在给予阿托品治疗症状性心动过缓以及给予胰高血糖素以逆转β受体阻滞剂活性(因为对初始阿托品治疗反应不佳)后,心率短暂改善至43次/分钟。然而,她的血压降至70/40 mmHg,需要输注多巴胺。实验室检查结果显示血尿素氮(BUN)显著升高至114 mg/dL,肌酐为12.4 mg/dL(基线肌酐为6 mg/dL),以及严重的高钾血症,血钾为7.9 mEq/L。这些结果促使立即给予静脉注射葡萄糖酸钙和胰岛素 - 葡萄糖输注治疗,同时口服环硅锆酸钠和沙丁胺醇雾化吸入。患者因心源性休克伴难治性心动过缓和急性肾损伤伴严重高钾血症需要血液透析而被收入重症监护病房。她接受了紧急血液透析,高钾血症得到缓解,心率改善至68次/分钟,心律转为窦性,因此无需放置起搏器。她开始门诊透析后出院回家。早期识别BRASH综合征至关重要,因为其治疗方法与标准的高级心血管生命支持(ACLS)心动过缓算法有显著不同。与标准方法不同,BRASH综合征的治疗不仅限于阿托品和电解质纠正,还可能包括血流动力学血管升压药支持、临时经皮起搏和紧急肾脏替代治疗。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4c8e/12456856/825731aed00e/cureus-0017-00000090898-i06.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4c8e/12456856/f1e19a8aa18d/cureus-0017-00000090898-i01.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4c8e/12456856/c34404aa1ed0/cureus-0017-00000090898-i02.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4c8e/12456856/6f6445de913c/cureus-0017-00000090898-i03.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4c8e/12456856/5017f9cd354e/cureus-0017-00000090898-i04.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4c8e/12456856/a739a15c2641/cureus-0017-00000090898-i05.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4c8e/12456856/825731aed00e/cureus-0017-00000090898-i06.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4c8e/12456856/f1e19a8aa18d/cureus-0017-00000090898-i01.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4c8e/12456856/c34404aa1ed0/cureus-0017-00000090898-i02.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4c8e/12456856/6f6445de913c/cureus-0017-00000090898-i03.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4c8e/12456856/5017f9cd354e/cureus-0017-00000090898-i04.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4c8e/12456856/a739a15c2641/cureus-0017-00000090898-i05.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4c8e/12456856/825731aed00e/cureus-0017-00000090898-i06.jpg

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本文引用的文献

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BRASH Syndrome: A Rare Clinical Phenomenon.BRASH综合征:一种罕见的临床现象。
CJC Open. 2024 Apr 2;6(6):840-842. doi: 10.1016/j.cjco.2024.03.013. eCollection 2024 Jun.
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BRASH syndrome: A rare but reversible cause of sinus node dysfunction.
HeartRhythm Case Rep. 2024 Mar 19;10(6):398-401. doi: 10.1016/j.hrcr.2024.03.005. eCollection 2024 Jun.
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BRASH syndrome with a complete heart block- a case report.伴有完全性心脏传导阻滞的BRASH综合征——病例报告
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A Case Report of BRASH (Bradycardia, Renal Failure, Atrioventricular (AV) Blockage, Shock, and Hyperkalemia) Syndrome With a Challenging Diagnosis and Management Dilemma.一例伴有诊断难题与治疗困境的BRASH(心动过缓、肾衰竭、房室传导阻滞、休克和高钾血症)综合征病例报告
Cureus. 2023 Oct 3;15(10):e46413. doi: 10.7759/cureus.46413. eCollection 2023 Oct.
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A BRASH Diagnosis With a Timely Intervention.一个鲁莽的诊断和及时的干预。
Curr Probl Cardiol. 2023 Nov;48(11):101984. doi: 10.1016/j.cpcardiol.2023.101984. Epub 2023 Jul 18.
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BRASH Syndrome: Bradycardia, Renal Failure, AV Blockade, Shock, and Hyperkalemia.BRASH 综合征:心动过缓、肾衰竭、房室传导阻滞、休克和高钾血症。
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