An elderly woman found down with bradycardia and hypotension

Submitted by Alex Bracey, with edits by Pendell Meyers and Steve Smith

A female in her 70s with PMH of hypertension, coronary artery disease, and a remote history of an aortic valve replacement was brought into the ED after being found down by her son. On arrival she was confused. Her initial ECG is shown below.

What do you think?

- Sinus bradycardia with HR of ~50 BPM (plus artifact that mimics PVCs)

- Peaked T waves particularly visible in leads V1-V3, I, and aVL

- RBBB with QRS duration 152 ms (comparison to prior shows similar RBBB morphology but with QRS duration of 116 ms)

In addition to being bradycardic as seen on this ECG, she was also hypotensive, with systolic blood pressures maintaining around 60 mmHg.

At this point let’s review the most common causes of bradycardia and hypotension:
Drugs: AV nodal blockers, Calcium channel blockers
Ischemia: usually RCA occlusion leading to bradycardia via sinus bradycardia or AV blocks
Electrolytes: Hyperkalemia

With this patient’s history of CAD and HTN it may be inferred that the patient is likely on an AV nodal blocking agent (i.e., calcium channel blockers (CCB) or beta-blockers (BB)). A review of this patient’s chart indeed confirmed that this patient had been prescribed metoprolol succinate (extended release).

Based on the ECG it is likely that you have already surmised the other underlying pathology: hyperkalemia (as demonstrated by bradycardia, peaked T waves and widened QRS).

The astute ED physician and resident correctly identified this ECG as concerning for hyperkalemia and empirically gave insulin/dextrose, calcium gluconate, albuterol, and intravenous fluid. The patient also received push dose epinephrine for hypotension. Following these interventions, the initial potassium returned at 6.5. This is not a particularly high level by itself, but certainly can cause these ECG changes and hemodynamic problems in a synergistic relationship known as BRASH syndrome (Bradycardia, Renal failure, AV nodal blocking agents, Shock, and Hyperkalemia).

Here is the subsequently recorded ECG after therapies:

 - Normal sinus rhythm at a rate of 82

 - Small amount of reduction in T-wave amplitude/peakedness

 - Relative narrowing of QRS interval (136 ms)

The particular combination of bradycardia, renal failure (this patient had a creatinine of 1.64 without a history of renal disease), AV nodal blockade, shock, and hyperkalemia has been coined BRASH syndrome.

The BRASH syndrome was coined on social media, not yet in peer-reviewed literature (like OMI). This interesting article on EmCrit references many cases with all of these findings, but none gave it this name, so you will have a hard time searching PubMed for this syndrome!

Briefly, BRASH occurs when a patient taking AV nodal blockers develops renal failure leading to decreased clearance of both potassium and AV nodal blocking medications, with worsening bradycardia and hypotension resulting from hyperkalemia and increased serum levels of beta blockers. The decreased cardiac output and blood pressure further worsens the renal failure, and so on. Of course, a similar syndrome occurs in patients with pre-existing renal failure, dialysis patients in particular.

The ECG for these patients may manifest with the classic peaked T-waves and/or any of the 4 "B’s of hyperkalemia" in combination or isolation, including Broad (Widened QRS), Brady, Bizarre, Blocks (AV blocks).

Upon further questioning, the patient’s husband recalls that the patient continued taking her supplemental potassium but had recently stopped her torsemide. She was subsequently admitted to the intensive care unit where her hyperkalemia was managed with insulin and diuretics. Her subsequent ECGs remained unchanged.

Teaching Points:

1) Expedient ECG interpretation is paramount in the presentation of bradycardic, hypotensive patients.

2) The combination of bradycardia and hypotension will most commonly be caused by one of three etiologies remembered by the mnemonic "DIE": Drugs (e.g., AV nodal blockers), Ischemia (acute coronary occlusion), and Electrolytes (esp. potassium).

3) In BRASH syndrome, a patient taking an AV nodal blocking medication develops renal failure and hyperkalemia which manifests on the ECG with peaked T-waves and/or any of the 4 B’s of hyperkalemia:  Broad (Widened QRS), Brady, Bizarre, Blocks (AV Blocks).

Comments by KEN GRAUER, MD (6/6/2018):
SUPERB Case !!! I’ll add 2 points: 
  • i) The BEST proof of Artifact, is when you are able to see the underlying rhythm continue undisturbed throughout the tracing. BLUE arrows in Figure-1 show evidence that the QRS continues here throughout the long-lead rhythm strip V5 — which proves that the large deflections “X” and “Y” cannot be real. And a look at simultaneously-recorded leads (within the dotted BLUE rectangle) proves that deflection “Z” is not an extra beat, but rather a distorted ST-T wave. 
  • ii) The T wave peaking seen with hyperkalemia applies not only to T waves that are positive — but also to T waves that are negative. Note how “pointed” the inverted T waves in leads V1, V2, V3 are — and that while still deeply inverted, this “point” smoothens out after correction of hyperkalemia.
Figure-1: Blue arrows show the underlying rhythm continues throughout.

Flying Or Diving After Traumatic Pneumothorax: Part 1

Today, I’m dusting off an old post on flying and diving after pneumothorax. This shows the thinking up until last year. Tomorrow, I’ll write about a new paper that suggests that we can shorten the “no-fly” time considerably.

Hint: no changes to the diving recommendations. One pneumothorax is likely to ground you forever.

Patients who have sustained a traumatic pneumothorax occasionally ask how soon they can fly in an airplane or scuba dive after they are discharged. What’s the right answer?

The basic problem has to do with Boyle’s Law (remember that from high school?). The volume of a gas varies inversely with the barometric pressure. So the lower the pressure, the larger a volume of gas becomes. Most of us hang out pretty close to sea level, so this is not an issue. But for flyers or divers, it may be.


Helicopters typically fly only one to two thousand feet above the ground, so the air pressure is about the same as standing on the earth. However, flying in a commercial airliner is different. Even though the aircraft may cruise at 30,000+ feet, the inside of the cabin remains considerably lower though not at sea level. Typically, the cabin altitude goes up to about 8,000 to 9,000 feet. Using Boyle’s law, any volume of gas (say, a pneumothorax in your chest), will increase by about a third on a commercial flight.

The physiologic effect of this increase depends upon the patient. If they are young and fit, they may never know anything is happening. But if they are elderly and/or have a limited pulmonary reserve, it may compromise enough lung function to make them symptomatic. And having a medical problem in an aluminum tube at 30,000 feet is never good.

Commercial guidelines for travel after pneumothorax range from 2-6 weeks. The Aerospace Medical Association published guidelines that state that 2-3 weeks is acceptable. The Orlando Regional Medical Center reviewed the literature and devised a practice guideline that has a single Level 2 recommendation that commercial air travel is safe 2 weeks after resolution of the pneumothorax, and that a chest x-ray should be obtained immediately prior to travel to confirm resolution.


Diving would seem to be pretty safe, right? Any pneumothorax would just shrink while the diver was at depth, then re-expand to the original size when he or she surfaces, right?

Not so fast. You are forgetting why the pneumothorax was there in the first place. The lung was injured, most likely via tearing it, penetration by something sharp, or popping a bleb. If the injured area has not completely healed, then air may begin to escape through it again. And since the air used in scuba diving is delivered under pressure, this could result in a tension pneumothorax.  This is disastrous underwater!

Most injuries leading to pneumothorax heal completely. However, if there are bone spicules stuck in the lung or more complicated parenchymal injuries from penetrating injury, they may never completely heal. This makes the diver susceptible to a tension pneumothorax anytime they use their regulator.

Bottom line: Most patients can safely travel on commercial aircraft 2 weeks after resolution of pneumothorax. Ideally, a chest xray should be obtained shortly before travel to confirm that it is gone. Helicopter travel is okay at any time, since they typically fly at 1,500 feet or less.

Divers should see a physician trained in dive medicine to evaluate their injury and imaging prior to making another dive.

Tomorrow: new info on flying after pneumothorax


  • Divers Alert Network – Pneumothorax – click to download
  • Practice Guideline, Orlando Regional Medical Center. Air travel following traumatic pneumothorax. October 2009.
  • Medical Guidelines for Airline Travel, 2nd edition. Aerospace Medical Association. Aviation, Space, and Environmental Medicine 74(5) Section II Supplement, May 2003.

Facing the future: standards for children in emergency care settings

Today saw the launch of the new RCPCH ‘Facing the Future’ document – setting standards for paediatric emergency care in the UK. These are a set of standards that should apply to all Emergency Department where children are seen and assessed.

The goal is for all emergency care services to be able to audit themselves against these standards.

It’s a 90 page document and you can read the full version here.

Here is our summary of the key points:


1. An integrated urgent and emergency care system

  • The focus is on a whole system approach where all services work together in established clinical networks – including GP services, urgent care centres, acute paediatric services, schools, pharmacy, community services, and ambulance services. They should have shared care guidelines, and evaluation processes across the whole network.
  • Staff in urgent care centres should have appropriate paediatric competence.


2. Environment in emergency care settings

  • Provide an appropriate waiting area including refreshments, breast-feeding facilities, and entertainment.
  • Involve children and young people and their parents in service design.
  • Have access to a play specialist.
  • Encourage patient/parent feedback.
  • Provide appropriate discharge information including written and verbal safety-netting.
  • Use patient flow models when planning the use of the environment.


3. Workforce and training

  • Every ED treating children should have a PEM consultant and two children’s nurses on a shift.
  • Staff should have professional development training hours for learning events.
  • A member of staff with APLS should be on duty and all staff should have BLS.
  • PEM Consultants should have SPAs in their job plans.


4. Management of the sick or injured child

  • Where children are being streamed away from ED this must be done by someone with paediatric competences
  • All children should be visually assessed on arrival by a doctor or nurse and have a clinical assessment (for triage) within 15 minutes. There should be an escalation policy when the triage wait exceed this.
  • All children should have a pain score and vital signs within 15 minutes.
  • Children with abnormal vital signs should have their obs repeated within 60 minutes.
  • Every ED should have an early warning system in place and an escalation policy for critically unwell children
  • The appropriate range of drugs and equipment should be available.
  • Children with moderate and severe pain should have analgesia dispensed within 20 minutes and a reassessment of their pain score within 60 minutes.
  • Health promotion and prevention should be delivered and recorded in the notes.
  • Discharge summaries should be sent to the relevant healthcare professionals within 24 hours.
  • The ED should work with community services to prevent hospital admissions.


5. Safeguarding in emergency care settings

  • All staff looking after children should have up-to-date safeguarding training.
  • There should be a lead consultant and nurse for safeguarding.
  • There should be departmental safeguarding guidelines.
  • All staff should have access to 24 hour safeguarding advice from a paediatrician with expertise.
  • All staff should have access to Child Protection Plan information, systems should be in place to identify frequent attenders, and staff should recognise the impact of a carer’s health on the dependent.
  • The primary care team should be informed of each attendance and an approved information sharing system should be in place.
  • There should be a policy for when a child leaves or absconds unexpectedly, and a review of the notes should be undertaken by a senior doctor or nurse for all children who leave before being seen.
  • All children with potential safeguarding presentations should be reviewed by ST4+.


6. Mental health

  • All children should have their emotional and mental health needs assessed.
  • Risk and capacity should be documented for all patients with a mental health crisis.
  • Have an appropriate space (including a safe room) for children/families in crisis.
  • Have access to mental health records and crisis plans (can be via CAMHS) and an appropriate escalation pathway.
  • Clinicians should be provided with training on assessing risk, capacity, consent, and parental responsibility.
  • Have 24 hour access to a mental health practitioner.
  • Have a policy for managing the acutely distressed young person.
  • Have a suitable inpatient facility to look after patients requiring an inpatient mental health facility where there is a delay in accessing it.
  • Have a clear pathway to identify a place of safety for those on a Section 136 order


7. Children with complex medical needs

  • Have a triage system that considers the prioritising care for children with complex medical needs and provide training on early escalation.
  • Have individual emergency care plans available and ensure any electronic alerts are used to show special instructions.
  • Consider the child with complex needs when designing and planning for the department.
  • Share information about attendances with the relevant professionals.


8. Major incidents involving children and young people

  • Ensure that children are specifically considered in planning for a major incident response and involve paediatric staff in incident exercises.


9. Safe transfers

  • Each region should have a Paediatric Critical Care transport team managed by the Paediatric Critical Care Operational Delivery Network.
  • Have access to a regional PICU with a 24 hour helpline providing support and advice.
  • Have local facilities and staff for time-critical transfers.
  • Have ED staff trained in patient stabilisation and transfer.
  • Provide information and practical help for families where children are transferred between hospitals.


10. Death of a child

  • There should be a local policy for responding to the unexpected death of a child.
  • Children who have died outside hospital should be taken to a hospital with paediatric facilities.
  • All staff should have training on how to support families where there is an unexpected death.
  • There should be co-operation with the Rapid Response team and the Child Death Overview panel.


11. Information system and data analysis

  • All ED staff should have an information system providing episode related information and demographics.
  • All health organisations providing emergency care should collaborate with national information centres.
  • All EDs treating children should collect performance data to improve services.
  • All EDs treating children should have discharge summaries compliant with PRSB standards.


12. Research for paediatric emergency care

  • All EDs treating children should have a nominated lead for paediatric emergency research with PERUKI membership.
Cite this article as:
Davis, T. Facing the future: standards for children in emergency care settings, Don't Forget the Bubbles, 2018. Available at:

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