{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T12:07:27Z","timestamp":1784117247181,"version":"3.55.0"},"reference-count":10,"publisher":"Wiley","issue":"1","license":[{"start":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T00:00:00Z","timestamp":1784073600000},"content-version":"vor","delay-in-days":195,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,1,1]],"date-time":"2026-01-01T00:00:00Z","timestamp":1767225600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Case Reports in Critical Care"],"published-print":{"date-parts":[[2026,1]]},"abstract":"<jats:p>Digoxin, a cardiac glycoside historically used for rate control in atrial arrhythmias and symptom relief in chronic heart failure, possesses a narrow therapeutic index and is highly susceptible to pharmacokinetic and pharmacodynamic disruption in critically ill patients. Its use in acute decompensated heart failure and cardiogenic shock is therefore controversial. We present the case of a 75\u2010year\u2010old woman with chronic heart failure with reduced ejection fraction who developed progressive bradycardia and cardiogenic shock after treatment with digoxin and amiodarone for 2:1 atrial flutter. Her hospital course was complicated by acute kidney injury, severe hyperkalemia, ischemic hepatitis, and persistent bradycardia following electrical cardioversion. Serum digoxin levels were supratherapeutic early in the intensive care unit course and subsequently normalized, though bradyarrhythmias persisted. The patient\u2032s presentation and clinical trajectory were consistent with BRASH (bradycardia, renal failure, AV\u2010nodal blockade, shock, and hyperkalemia) syndrome , with amiodarone\u2013digoxin interaction and systemic hypoperfusion likely amplifying myocardial digoxin sensitivity. She improved with supportive therapy, correction of metabolic derangements, withdrawal of AV\u2010nodal\u2010blocking agents, and cardioversion, without administration of digoxin\u2010specific antibody fragments. This case highlights the importance of early recognition of BRASH physiology, cautious use of AV\u2010nodal blockers in low\u2010output states, and prioritization of underlying physiologic correction over reliance on serum drug levels alone in critically ill patients.<\/jats:p>","DOI":"10.1155\/crcc\/8778210","type":"journal-article","created":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T11:17:31Z","timestamp":1784114251000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["BRASH Syndrome Unmasked: Digoxin Toxicity in the Setting of Cardiogenic Shock and Multiorgan Dysfunction"],"prefix":"10.1155","volume":"2026","author":[{"ORCID":"https:\/\/orcid.org\/0009-0004-3253-8283","authenticated-orcid":false,"given":"Spencer","family":"Boehm","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jordan","family":"Bruni","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,7,15]]},"reference":[{"key":"e_1_2_10_1_2","doi-asserted-by":"publisher","DOI":"10.1161\/01.CIR.99.9.1265"},{"key":"e_1_2_10_2_2","first-page":"395","article-title":"Clinical Considerations in the Use of Digoxin in Heart Failure","volume":"12","author":"Allen L. A.","year":"2006","journal-title":"Journal of Cardiac Failure"},{"key":"e_1_2_10_3_2","doi-asserted-by":"publisher","DOI":"10.1161\/01.CIR.0000132482.95686.87"},{"key":"e_1_2_10_4_2","first-page":"877","article-title":"Therapeutic Uses of Digoxin: A Tale of Two Indications","volume":"59","author":"Goldberger Z. D.","year":"2012","journal-title":"Journal of American College of Cardiology"},{"key":"e_1_2_10_5_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIR.0000000000001063"},{"key":"e_1_2_10_6_2","first-page":"489","article-title":"Amiodarone\u2013Digoxin Interaction: Clinical Significance, Time Course of Development, Potential Pharmacokinetic Mechanisms, and Therapeutic Implications","volume":"91","author":"Bach D. S.","year":"2024","journal-title":"Cleveland Clinic Journal of Medicine"},{"key":"e_1_2_10_7_2","volume-title":"BRASH syndrome: Bradycardia, Renal Failure, AV-Nodal Blockade, Shock, and Hyperkalemia","author":"Farkas J. D.","year":"2025"},{"key":"e_1_2_10_8_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.hrcr.2024.03.005"},{"key":"e_1_2_10_9_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.cjco.2024.03.013"},{"key":"e_1_2_10_10_2","doi-asserted-by":"publisher","DOI":"10.7759\/cureus.97221"}],"container-title":["Case Reports in Critical Care"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1155\/crcc\/8778210","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1155\/crcc\/8778210","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1155\/crcc\/8778210","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T11:17:33Z","timestamp":1784114253000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1155\/crcc\/8778210"}},"subtitle":[],"editor":[{"given":"Naohiro","family":"Komura","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,1]]},"references-count":10,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2026,1]]}},"alternative-id":["10.1155\/crcc\/8778210"],"URL":"https:\/\/doi.org\/10.1155\/crcc\/8778210","archive":["Portico"],"relation":{},"ISSN":["2090-6420","2090-6439"],"issn-type":[{"value":"2090-6420","type":"print"},{"value":"2090-6439","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1]]},"assertion":[{"value":"2026-01-24","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-06-10","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-07-15","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"8778210"}}