A Former Cocaine User Whose Specialist Told Her She's Dying

Catherine M. Divingian, MD, PhD; Mityanand Ramnarine, MD; Jeffrey Jordan, MD


February 02, 2021


Surreptitious cocaine use is unlikely in this case. Although some patients with cocaine overdose may have no symptoms - tachycardia, hypertension, and hyperthermia are common.[1] Whereas this patient has bradycardia and is normothermic.

Hyperosmolar hyperglycemic syndrome is marked by elevated glucose levels and possible sodium derangements; however, in contrast to the findings in this patient, the potassium level is typically normal in hyperosmolar hyperglycemic syndrome, and bradycardia is not expected.[2]

Patients with end-stage renal failure secondary to diabetes mellitus typically present with electrolyte abnormalities, particularly hyperkalemia, and elevated BUN and creatinine levels. However, they usually do not have bradycardia.[3,4]

Chronic pancreatitis is frequently associated with abdominal pain, nausea, vomiting, and steatorrhea and resulting fat-soluble vitamin deficiencies. Weight loss is also common.[5] The patient in this case reported none of these symptoms.

This patient has the classic presentation of bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia (BRASH) syndrome. The signs and symptoms may initially appear disjointed making the diagnosis challenging. Additionally, the syndrome has recently been recognized, with the first description being published in 2016; thus, the pathophysiology and treatment are still poorly understood, and the condition may go unrecognized.[6,7,8,9,10]

To mitigate morbidity and mortality, emergency medicine providers, in particular, must be able to recognize BRASH syndrome and intervene early. Identifying the syndrome accurately is important because advanced cardiac life support (ACLS) and standard resuscitation protocols may worsen outcomes. Patients with BRASH syndrome may have a poor response to typical 'cookbook' algorithms if they are applied individually.[6,7,8] Fortunately, in this case, a medical student who was working in the ED recognized the patient's syndrome, and appropriate interventions were started in the ED before she was admitted.


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