RCP

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2019 American Heart Association Guidelines Update on 
Adult Advanced 
Cardiovascular Life Support
Advanced Airways During CPR
2019 Recommendation: Bag-mask ventilation or advanced 
airway can be considered for adult CPR in any setting.
Out-of-Hospital
Advanced Airway Needed
If high endotracheal 
(ET) tube success 
rate/optimal ET tube 
training opportunities
If low ET tube success 
rate/minimal ET tube 
training opportunities
Supraglottic airway or 
ET tube can be used
Supraglottic airway can 
be used
EMS systems performing prehospital intubation 
should have a quality improvement program 
to minimize complications and track intubation 
success rates.
In-Hospital
Advanced Airway Needed
If providers are trained 
in advanced airways
Supraglottic airway or 
ET tube can be used
Providers performing ET intubation require 
frequent experience and retraining.
Recommendations assume providers 
have adequate training and skills to 
perform the procedures. Providers must 
also have the capacity to clinically assess 
when advanced airways are needed.
Vasopressors During CPR
It is reasonable to administer 1 mg of 
epinephrine every 3 to 5 minutes.
2019 Recommendation: It is 
recommended that epinephrine 
be administered for cardiac arrest.
Randomized controlled trials (RCTs) demonstrated improved 30-day survival and 
survival to discharge.
However, epinephrine was not shown to increase rates of survival with favorable 
neurological outcome. Although 1 large study found an increase in short-term 
survival with unfavorable neurological outcome, this difference did not persist for 
more than 30 days.
The benefits of epinephrine support the recommendation 
for its use, despite some remaining uncertainty about 
overall impact on neurological outcome.
Standard-Dose
Epinephrine
vs
High-Dose
Epinephrine
Since 2015, no new studies were identified, 
so the 2015 recommendation of standard-
dose epinephrine remains unchanged.
Epinephrine
vs
Vasopressin
Vasopressin may be considered in cardiac 
arrest, but it offers no advantage as a 
substitute for epinephrine.
Although studies 
showed vasopressin or
vasopressin + 
epinephrine was equal 
to epinephrine, the 
AHA recommends 
epinephrine alone to 
maintain simplicity 
in the cardiac arrest 
algorithm.
Epinephrine
vs
Epinephrine
and
Vasopressin
Vasopressin combined with epinephrine may 
be considered in cardiac arrest, but it offers no 
advantage as a substitute for epinephrine alone.
Dose and Timing of Epinephrine Administration
16
observational studies
10
of which compared early 
vs late administration of 
epinephrine
2019 Recommendations 
It may be reasonable to administer 
epinephrine after defibrillation 
attempts have failed.
It is reasonable to administer 
epinephrine as soon as feasible.
Extracorporeal CPR
Extracorporeal 
CPR refers to a 
cardiopulmonary 
bypass, which 
maintains organ 
perfusion while cardiac 
arrest causes are 
addressed.
Arterial Blood
Oxygenator
Pump
Venous Blood
Extracorporeal CPR is performed with an 
extracorporeal membrane oxygenation device. 
It includes a venous cannula, a pump, an 
oxygenator, and an arterial cannula.
2019 Recommendations 
Extracorporeal CPR is not 
recommended for routine 
use in cardiac arrest.
Consider extracorporeal 
CPR when conventional 
CPR is failing and if 
providers are skilled and 
can implement it quickly.
Why?
RCTs No published RCTs assessed 
ECPR in cardiac arrest.
Observational 
Studies
Although results were inconsistent 
across studies, some found improved 
survival and neurological outcome 
in select patients treated with 
extracorporeal CPR.
Systematic 
Review
Most studies used young, healthy 
patients but no current method 
to identify ideal patients.
Guidelines provided by
Template and infographic designed by Sparsh Shah, MD candidate, and Andrew 
Tolmie, MD candidate. Edited by Alvin Chin, MD, MSc, and Comilla Sasson, MD, PhD. 
Reviewed by Teresa Chan, MD, and Brent Thoma, MD.
CPR.heart.org KJ-1416 11/19 © 2019 American Heart Association
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