Emergency Medical Minute

Contributor: Aaron Lessen, MD
Educational Pearls
BRASH Syndrome:
Bradycardia

Renal Failure

AV Nodal Blockade

Shock

Hyperkalemia 

Clinical Features:
Profound bradycardia and shock in patients on AV nodal blockers:

Commonly, Beta Blockers or Calcium Channel Blockers

Etiology: 
Caused by an inciting kidney injury:

Common triggers include precipitating illness, dehydration, or medications 

Results in hyperkalemia

The enhanced effect of the combination of AV nodal blockade and hyperkalemia leads to a more profound presentation of shock.

Treatment: 
IV Fluids, unless volume overloaded

Epinephrine for bradycardia

Lasix for volume overload, only if the patient is still making urine

Low threshold to dialyze for hyperkalemia
Focus on treating early and more aggressively. 

References:
Farkas JD, Long B, Koyfman A, Menson K. BRASH Syndrome: Bradycardia, Renal Failure, AV Blockade, Shock, and Hyperkalemia. J Emerg Med. 2020 Aug;59(2):216-223. doi: 10.1016/j.jemermed.2020.05.001. Epub 2020 Jun 18. PMID: 32565167.
 
Summarized by Ashley Lyons OMS3
Editting by Ashley Lyons OMS3 and Jeffrey Olson MS4
 
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Contributor: Taylor Lynch, MD
Educational Pearls:
What is tramadol and how does it work?
Tramadol is a Schedule IV opioid analgesic used for moderate pain and is often perceived as safer than other opioids due to lower abuse potential.

It is a prodrug with weak direct μ-opioid receptor activity.

The parent compound also inhibits serotonin and norepinephrine reuptake, giving it SSRI/SNRI-like properties.

Tramadol is metabolized by CYP2D6 into O-desmethyltramadol (ODT), which has significantly stronger μ-opioid receptor agonism than the parent drug.

What are the concerns with tramadol?
Ultrarapid CYP2D6 metabolizers (more common in Middle Eastern and North African populations) rapidly convert tramadol to ODT, increasing the risk of opioid toxicity.

Poor CYP2D6 metabolizers generate little ODT and may experience primarily serotonergic effects, increasing the risk of serotonin syndrome, especially when combined with SSRIs or SNRIs.

CYP2D6 inhibitors (e.g., bupropion, paroxetine, terbinafine, celecoxib) can block tramadol's conversion to ODT, potentially precipitating opioid withdrawal or increasing serotonergic toxicity.

Tramadol is also associated with an increased risk of first-time seizures, even at therapeutic doses.

Key takeaways
Tramadol's effects are highly unpredictable, varying from minimal analgesia to exaggerated opioid effects depending on metabolism.

Drug–drug interactions can lead to serotonin syndrome or opioid withdrawal.

Despite its Schedule IV classification and reputation for safety, alternative analgesics may be preferable in many patients.

References
DailyMed - TRAMADOL HYDROCHLORIDE tablet, coated. Accessed January 10, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=61fb5ba7-6896-4ee4-83de-caee69b06a8e#ID57

Dean L, Kane M. Tramadol Therapy and CYP2D6 Genotype. In: Pratt VM, Scott SA, Pirmohamed M, Esquivel B, Kattman BL, Malheiro AJ, eds. Medical Genetics Summaries. National Center for Biotechnology Information (US); 2012. Accessed January 10, 2026. http://www.ncbi.nlm.nih.gov/books/NBK315950/

Aly SM, Tartar O, Sabaouni N, Hennart B, Gaulier JM, Allorge D. Tramadol-Related Deaths: Genetic Analysis in Relation to Metabolic Ratios. J Anal Toxicol. 2022;46(7):791-796. doi:10.1093/jat/bkab096

Summarized and edited by Dan Orbidan OMS2
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Contributor: Aaron Lessen, MD
Educational Pearls:
The Case
24F brought in for anxiety. Patient is tearful, not talking, and potentially hyperventilating. History from boyfriend is that she suddenly stopped talking and started crying and it was hard to understand what she was saying. On exam, patient appears anxious and has a gaze preference for the right side and is still having difficulty speaking.

Decision is made to stroke alert patient.

CT shows early MCA stroke and M2 occlusion.

Patient is treated by IR with mechanical thrombectomy.

What are the risk factors for strokes in young people ( Traditional risk factors still matter

Hypertension 

Most important modifiable risk factor, present in 30-50% of young stroke patients

Diabetes

Especially insulin dependent type 1

HLD

Smoking

Substance use

Cocaine

Meth

Alcohol, especially binge drinking

IV drug use

Structural heart disease

PFO

Valvular heart disease like rheumatic disease

Hypercoagulable states

Factor V Leiden

Protein C or S deficiency

Antithrombin III deficiency

Vertebral dissections

Recent trauma

References
Aigner A, Grittner U, Rolfs A, Norrving B, Siegerink B, Busch MA. Contribution of Established Stroke Risk Factors to the Burden of Stroke in Young Adults. Stroke. 2017 Jul;48(7):1744-1751. doi: 10.1161/STROKEAHA.117.016599. Epub 2017 Jun 15. PMID: 28619986.

Ekker MS, Boot EM, Singhal AB, Tan KS, Debette S, Tuladhar AM, de Leeuw FE. Epidemiology, aetiology, and management of ischaemic stroke in young adults. Lancet Neurol. 2018 Sep;17(9):790-801. doi: 10.1016/S1474-4422(18)30233-3. PMID: 30129475.

Khan M, Wasay M, O'Donnell MJ, Iqbal R, Langhorne P, Rosengren A, Damasceno A, Oguz A, Lanas F, Pogosova N, Alhussain F, Oveisgharan S, Czlonkowska A, Ryglewicz D, Yusuf S. Risk Factors for Stroke in the Young (18-45 Years): A Case-Control Analysis of INTERSTROKE Data from 32 Countries. Neuroepidemiology. 2023;57(5):275-283. doi: 10.1159/000530675. Epub 2023 May 17. PMID: 37231971.

Summarized and edited by Jeffrey Olson MS4
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Contributor: Aaron Lessen, MD
Educational Pearls:
A 2025 multistate outbreak of infant botulism has been linked to ByHeart infant formula
As of December 10-17th, there have been at least 51 infants with suspected or confirmed botulism who were exposed to this formula across 19 states

All reported cases resulted in hospitalization but no deaths reported to date

Infant botulism
 Occurs when C. botulinum spores germinate in the infant's intestine, producing toxin

Spores are classically found in honey but can also be in dirt or contaminated in infant formula

Infants are particularly susceptible because their body can't neutralize the spores

Symptoms may include initial constipation, poor feeding, weak cry, floppy movements, loss of head control, difficulty swallowing, generalized weakness, and respiratory compromise if progressive

Can be treated with antitoxin 

Maintain a high index of suspicion for infant botulism in infants fed the recalled formula presenting with neuromuscular symptoms. 

References
Human Foods Program. Outbreak Investigation of Infant Botulism: Infant Formula. U.S. Food and Drug Administration. Published 2025. https://www.fda.gov/food/outbreaks-foodborne-illness/outbreak-investigation-infant-botulism-infant-formula-november-2025

Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jeffrey Olson, MS4
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