A Case of BRASH Syndrome, Refractory Acidosis Necessitating Multimodal Approach to Treat it

A 69-year-old female patient, with hypertension and diabetes mellitus, was brought to Emergency Department in unresponsive state. The initial evaluation revealed that the patient had wide complex junctional bradycardia owing to hyperkalemia; hypoglycaemia, metabolic acidosis. Treatment was started in an attempt to establish definitive airway; correct glucose levels, cardiac membrane stabilisation. Interim, patient had a cardiac arrest and the Return Of Spontaneous Circulation (ROSC) was achieved and then stabilised. Later, she was found to have viral hepatitis complicated with ischemic hepatitis due to urosepsis. Managing a coding patient with severe metabolic acidosis in a resource limited setting is always challenging. Numerous paradoxes including usage of alkali therapy, choice of inotropes, achievement of haemodynamic neutral intubation is extensively studied yet debated. The present case encompasses the difficulties and possible solutions in managing such patient with refractory acidosis, Bradycardia, Renal failure, AV nodal blockers, Shock, Hyperkalemia syndrome (BRASH).