Management of Bradycardia in a Moribund Patient
In a moribund (dying) patient with bradycardia, focus on comfort measures and avoid aggressive interventions unless there is a reversible cause and the patient has expressed wishes for full resuscitation. 1
Initial Assessment
Determine goals of care immediately before initiating any treatment, as this fundamentally changes management in moribund patients. 1
- Assess whether the patient has advance directives or documented wishes regarding resuscitation 1
- Evaluate if bradycardia represents the terminal phase of underlying disease versus a potentially reversible acute process 1
- Consider functional status, life expectancy, and quality of life priorities in decision-making 1, 2
If Full Resuscitation is Desired
Immediate Pharmacologic Management
Administer atropine 0.5-1 mg IV as first-line therapy, repeating every 3-5 minutes to a maximum total dose of 3 mg. 1, 3 However, recognize that atropine has significant limitations:
- Doses less than 0.5 mg may paradoxically worsen bradycardia and should be avoided 1, 3, 4
- Atropine is likely ineffective in type II second-degree or third-degree AV block with wide QRS complexes, where the block is infranodal 1, 3
- In moribund patients with severe underlying cardiac disease, atropine may cause paradoxical high-grade AV block 1, 5
Second-Line Interventions
If atropine fails, initiate IV epinephrine infusion at 2-10 mcg/min, titrated to hemodynamic response. 1, 3 This is preferred over dopamine in moribund patients because:
- Epinephrine provides more potent chronotropic and inotropic effects when urgent support is needed 3
- Dopamine at 5-10 mcg/kg/min is an alternative but requires more careful titration 1, 3
- Both agents increase myocardial oxygen demand and may worsen ischemia if present 1, 3
Transcutaneous Pacing
Consider transcutaneous pacing only if the patient remains unstable despite medications and has a potentially reversible cause. 1, 3 Important caveats:
- Transcutaneous pacing is extremely painful in conscious patients and requires sedation/analgesia 3
- It serves only as a temporizing measure, not definitive therapy 3
- In truly moribund patients, pacing may prolong suffering without improving meaningful outcomes 1
If Comfort-Focused Care is Appropriate
Provide symptomatic relief without attempting to correct the bradycardia itself. 1
- Ensure adequate oxygenation and positioning for comfort 6
- Treat associated symptoms (dyspnea, anxiety, pain) with appropriate palliative medications 1
- Avoid atropine, vasopressors, and pacing, as these interventions may prolong the dying process without improving quality of life 1
Critical Pitfalls to Avoid
Do not reflexively treat bradycardia in moribund patients without first establishing goals of care. 1 Common errors include:
- Administering atropine in patients with infranodal blocks, which can precipitate complete heart block and ventricular standstill 1, 5
- Using chronotropic agents in acute myocardial infarction, which increases infarct size and worsens outcomes 1, 3
- Pursuing aggressive interventions (pacing, vasopressors) in patients with terminal illness where bradycardia represents the natural dying process 1
- Delaying comfort measures while attempting futile resuscitation 1
Special Considerations
In the approximately 20% of patients requiring temporary pacing for stabilization, recognize this is only appropriate if there is a reversible cause and the patient desires aggressive intervention. 7 The 30-day mortality for compromising bradycardia is approximately 5%, but this rises substantially in moribund patients with multiple comorbidities. 7
Aminophylline 6 mg/kg IV over 20-30 minutes may be considered in atropine-resistant bradycardia if the patient is not actively dying and has a reversible cause (such as spinal cord injury or post-cardiac transplant), but this is rarely appropriate in truly moribund patients. 1, 8