Version August 2025
INTRODUCTION —
Resuscitative thoracotomy is a procedure of last resort performed only under specific clinical circumstances for patients who are actively dying. Resuscitative thoracotomy is most frequently performed in the emergency department and involves gaining rapid access to the heart and major thoracic vessels through a transverse chest incision to control exsanguinating noncompressible torso hemorrhage, or other life-threatening chest injuries. The first successful resuscitative thoracotomy was described for the resuscitation of a patient with penetrating cardiac injury, and this indication remains the one associated with the highest rate of survival [1,2].
This topic will briefly review the indications for resuscitative (emergency department) thoracotomy, which are discussed more fully in separate reviews, as well as contraindications and alternatives (eg, resuscitative endovascular balloon occlusion), and describe the surgical technique.
The initial resuscitation, diagnostic evaluation, and management of the trauma patient with blunt or penetrating trauma is based upon protocols from the Advanced Trauma Life Support (ATLS) program established by the American College of Surgeons Committee on Trauma. The initial evaluation and resuscitation of the patient with blunt or penetrating abdominal or thoracic trauma is discussed elsewhere.
●(See "Initial evaluation and management of blunt thoracic trauma in adults".)
●(See "Blunt abdominal trauma in adults: Initial evaluation and management".)
●(See "Abdominal gunshot wounds in adults: Initial evaluation and management".)
●(See "Initial evaluation and management of abdominal stab wounds in adults".)
NONCOMPRESSIBLE TORSO HEMORRHAGE —
Resuscitative thoracotomy is one temporizing measure for managing noncompressible torso hemorrhage. Resuscitative thoracotomy allows direct control of hemorrhage from noncompressible exsanguinating thoracic injuries, decompression of cardiac tamponade, and allows control of the aorta to limit bleeding from infradiaphragmatic injuries to facilitate resuscitation.
Resuscitative thoracotomy is restricted to patients with specific indications as determined by the patient's clinical status en route and immediately upon arrival to the emergency department, the mechanism of injury (penetrating versus blunt injury), or the need to perform therapeutic maneuvers to manage correctable causes of shock, including decompressing cardiac tamponade, cross-clamping the aorta, managing exsanguinating cardiac or vascular injuries, and evacuating air embolism [3].
●Penetrating trauma – (algorithm 1) (See "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Role of emergency department thoracotomy'.)
●Blunt trauma – (algorithm 2) (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Role of emergency department thoracotomy'.)
Studies that have evaluated adherence to guidelines have shown compliance rates ranging from 50 to 80 percent [4-6]. Compliance is typically better for penetrating compared with blunt trauma (74 versus 45 percent, in one study [4]). Despite widespread recommendations against the use of resuscitative thoracotomy following blunt trauma in the absence of signs of life because of a lack of efficacy, persistent use of resuscitative thoracotomy in the emergency department was noted in these patients in a review from the American Association for Surgery in Trauma (AAST) Aorta Study Group [7].
Requirements for successful thoracotomy outcomes — Resuscitative thoracotomy should only be performed in settings where appropriate expertise and trained surgeons (eg, vascular, cardiothoracic, trauma) are available to provide definitive care. In all survivors, definitive surgical management will subsequently be required. Attempts to transfer patients to another facility with an aortic clamp in place are uniformly unsuccessful. (See 'Definitive management' below.)
A useful framework for the performance of resuscitative thoracotomy is derived from the European Resuscitation Council Guidelines, which advocates a "4 Es" approach to resuscitative thoracotomy [8]:
●Expertise – The team is led by a trained and competent provider under robust governance.
●Equipment – Adequate equipment is available to carry out the thoracotomy and manage the findings.
●Environment – Ideally, thoracotomy should be done in an operating room setting. The procedures should not be done if definitive care to manage identified injuries is not within reach.
●Elapsed time – The time from loss of vital signs to commencing thoracotomy does not exceed accepted values.
This framework is applicable to all trauma centers, assuming immediate surgical support and operating room access. Using the "4 Es" allows each center to evaluate the appropriateness of performing the procedure.
Indicators of futility — Outcomes (mortality, functional recovery) for resuscitative thoracotomy are strongly linked to appropriate patient selection. Given the risk of harm to the treating team (eg, bloodborne illness), initiating an invasive procedure in the face of futility is ill-advised. Failure to meet the requirements above or the listed criteria below is an indication of futility and a "hard stop" to performing resuscitative thoracotomy.
●Penetrating trauma – For patients with penetrating injury, resuscitative thoracotomy is likely to be futile in patients following circumstances:
•The patient has no signs of life at the scene of injury
•Asystole is the presenting rhythm and there is no pericardial tamponade
•Prolonged pulselessness (>15 minutes) occurs at any time
•Massive, nonsurvivable injuries have occurred
●Blunt trauma – For patients with blunt injury, resuscitative thoracotomy is likely to be futile if [9]:
•The patient has no signs of life at the scene of injury.
•The patient requires >10 minutes of cardiopulmonary resuscitation.
•Absence of an organized cardiac rhythm or absent cardiac activity on ultrasound evaluation [10,11].
•Massive, nonsurvivable injuries have occurred.
Decision for resuscitative thoracotomy or REBOA — Several reviews have compared the efficacy of resuscitative thoracotomy with endovascular balloon occlusion of the aorta (REBOA) [12,13]. The AAST Aorta Study Group concluded that REBOA offered a survival advantage over resuscitative thoracotomy, particularly in patients not requiring cardiopulmonary resuscitation [13,14]. However, later studies have questioned this advantage [15,16].
The decision to perform immediate resuscitative thoracotomy, REBOA placement, or to discontinue resuscitative efforts is a clinical decision based on the individual patient and circumstance. Considerations are based on the suspected injuries, loss of vital signs, time since loss of vital signs, the availability of required resources, and the expertise of the resuscitation team [17,18]. (See 'Requirements for successful thoracotomy outcomes' above and 'Indicators of futility' above.)
REBOA can be considered for patients with actual or impending traumatic cardiac arrest using the same indications as with resuscitative thoracotomy but without a thoracic source of hemorrhage or tension physiology (See "Endovascular methods for aortic control in trauma".)
In addition, for patients with abdominal or pelvic trauma, REBOA may offer a "physiological bridge" during resuscitation. (See "Abdominal vascular injury" and "Severe pelvic fracture in the adult trauma patient".)
Our approach is as follows for the following clinical categories:
●For unstable, deteriorating patients at risk of arrest prior to arriving in the operating room despite ongoing resuscitation.
•With concern for causative intrathoracic injuries:
-Resuscitative thoracotomy to allow for pericardial decompression, aortic compression, and bleeding control should be utilized rather than REBOA.
•Without concern for thoracic pathology:
-REBOA may be preferred if expertise for rapid placement is available and does not delay operative intervention.
●Traumatic cardiac arrest during hospital resuscitation in the absence of obvious additional nonsurvivable injuries.
•With concern for causative intrathoracic injuries:
-Resuscitative thoracotomy to allow for pericardial decompression, aortic compression, and bleeding control should be utilized rather than REBOA
•Without concern for thoracic pathology:
-REBOA or resuscitative thoracotomy may be used based on the team's experience with the procedures.
PREPARATION
General considerations — Once the decision has been made to open the chest, one member of the trauma team should be designated to lead the ongoing resuscitation effort while an experienced member of the trauma team is performing the thoracotomy. The team leader must be easily identified and should present a calm but authoritative demeanor. Personnel not actively engaged in a specific function directed by the team leader should be asked to leave the room. Remind all personnel to minimize unnecessary conversations and to remain calm and purposeful. Iatrogenic injury due to haste, inattention, or an overly chaotic environment must be minimized to improve the likelihood of a satisfactory outcome.
●While intubation and large-bore intravenous access are underway, completely disrobe the patient. Dual-lumen endotracheal intubation is not recommended in the emergency setting. A nasogastric or orogastric tube should be placed to aid localization of the esophagus when clamping the aorta. (See 'Cross-clamp the aorta' below.)
●Position the patient supine, with the arms placed on arm boards laterally or extended over the head. Large-bore intravenous access is essential. Initial access with intraosseous techniques in patients in extremis is more reliable than intravenous but does not replace the need for high-volume access [19,20].
●Prepare the skin quickly by pouring chlorhexidine gluconate or iodophor solution liberally over the entire thorax. Apply sterile drapes; in practice, a truly sterile field is rarely achieved.
●When a left-sided resuscitative thoracotomy is underway, simultaneously access the right pleural space to determine the presence of blood. A right-sided chest tube or simple "finger thoracotomy" is sufficient and can be performed by another member of the trauma team simultaneous with the thoracotomy procedure and should not delay the thoracotomy. If an initially right-sided thoracotomy approach is selected because massive bleeding from a right chest injury is suspected, similarly, a left-sided chest tube "finger thoracotomy" can be performed as described. If the patient is in cardiac arrest, access the left side first to facilitate relief of tamponade and open cardiac massage and then extend to a clamshell thoracotomy to manage massive hemorrhage in the right chest.
Equipment and supplies — A sterile thoracotomy tray (picture 1) should be available in the trauma room at all times. The tray should include sterile drapes or towels, laparotomy sponges, and appropriate instruments (table 1). The use of a specific checklist for resuscitative thoracotomy can be used to facilitate rapid deployment of necessary equipment and devices [21]. It is important to limit the instruments on the emergency thoracotomy tray to only those that are likely to be used. A comprehensive instrument set may be an impediment to efficient entry into the chest. Other useful instruments to have available include trauma shears, chest tubes, a Foley catheter with a 5 mL balloon, suture material (eg, Prolene, silk), and a skin stapler. (See 'Control hemorrhage' below.)
Lighting and suction are frequently inadequate in the emergency department setting. Every effort should be made to assure that an overhead surgical light or headlight is available, and that effective wall suction is nearby. Operating room personnel may be helpful if available.
Antibiotics — Antibiotics are recommended prior to cardiothoracic surgery (table 2). However, the procedure should not be delayed for antibiotic administration.
Universal precautions — Resuscitative thoracotomy is associated with significant blood splatter in often unpredictable directions. Given the increased risk of exposure to bloodborne disease in the trauma setting, we agree with ATLS recommendations that all personnel involved in the care of the trauma patient should observe universal precautions wearing gowns, gloves, and eye protection at all times. Any personnel not immediately involved in the thoracotomy procedure should stand away from the table to minimize their risk of exposure. After the procedure is completed, particular care should be exercised with disposal of sharp instruments. (See "Patient safety in the operating room" and "Prevention of hepatitis B virus and hepatitis C virus infection among health care providers", section on 'Epidemiology of bloodborne exposures'.)
The prevalence of bloodborne pathogens (eg, human immunodeficiency virus [HIV] and hepatitis B [Hep B] or hepatitis C [Hep C]) in the trauma population is well documented [22-30]. The estimated seroprevalence of HIV in injured patients in emergency departments in the United States is between 0.5 and 10 percent [31]. Hep B and C seroprevalence rates may be higher [25,32-34]. In one series evaluating these diseases in penetrating trauma patients (the subset of patients most likely to undergo resuscitative thoracotomy), infection with HIV or hepatitis was present in 9.4 percent. The prevalence of HIV was 1.2 percent, the prevalence of Hep B antigen was 0.6 percent, and the prevalence of Hep C was 7.6 percent [25,33,34]. The risk of infection following occupational exposure to HIV is relatively low (0.3 percent). Hepatitis is more readily transmitted through occupational exposure, with transmission rates for Hep B ranging from 6 to 30 percent and transmission rates for Hep C ranging from 0 to 7 percent [35].
The presence of bone fragments, the hurried nature of the procedure, and often difficult exposure poses a significant risk of transdermal exposure as well. Trainees are at highest risk to sharp exposure with an overall exposure risk of 7.2 percent [36].
THORACIC ANATOMY —
The thorax is the area of the body between the base of the neck superiorly and the diaphragm inferiorly. The thorax contains the heart, lungs, and major vascular structures, including the aorta, arch vessels (brachiocephalic, carotid, and subclavian arteries), and descending thoracic aorta (figure 1).
The aortic root is a midline structure, and the heart is normally positioned in the left chest with the apex of the left ventricle at the left midclavicular line. The arch of the aorta sweeps from the midline posteriorly to the left, and the descending thoracic aorta lies adjacent to the spine (figure 2). The arch of the aorta and great vessels are located beneath the manubrium of the sternum. The descending thoracic aorta is covered by a thin layer of parietal pleura that must be divided to expose it.
Normal aortic arch anatomy consists of three branches: the brachiocephalic trunk, which gives off the right common carotid and right subclavian arteries; the left common carotid artery; and the left subclavian artery. Variations of the aortic arch (figure 3) occur in approximately 17 percent of individuals [37,38]. The most common variation is a bovine arch with the left common carotid artery arising from a larger than usual brachiocephalic trunk.
The pericardial sac surrounds and protects the heart. The left phrenic and vagus nerves pass anterior to the aortic arch in proximity to the origin of the left subclavian artery. The left phrenic nerve adheres to the lateral surface of the pericardium (figure 4) and is particularly susceptible to inadvertent injury during resuscitative thoracotomy. The left vagus nerve gives rise to the left recurrent laryngeal nerve, which encircles the aortic arch just medial to the origin of the left subclavian artery. The left vagus nerve travels posterior to the root of the left lung and then adjacent to the esophagus as it descends in the posterior mediastinum. Due to its posterior location, it is less vulnerable to injury compared with the phrenic nerve.
The esophagus is located on the anterior surface of the spine and medial to the aorta. The thoracic duct ascends along the anterolateral surface of the spine, is virtually invisible, and is susceptible to traumatic avulsion that can result in chylothorax.
TECHNIQUES —
Although the technique of resuscitative thoracotomy is relatively straightforward, the procedure is often performed by those who do not routinely perform elective thoracotomy. A systematic approach can help the practitioner avoid pitfalls and optimize patient outcomes.
General considerations — Given the indications for resuscitative thoracotomy (ie, patient in extremis with loss of vital signs), the steps are generally performed in a defined order, which is discussed in more detail below. However, the clinical presentation of the patient or the nature of a specific injury may make one step take precedence over another. As an example, aortic cross-clamping may take precedence over pericardiotomy in the patient with exsanguinating hemorrhage from an aortic rent. In general:
●Stop external chest compressions prior to thoracotomy. Ongoing chest compressions may delay or complicate the most critical aspects of resuscitation (ie, establishment of intravenous access, endotracheal intubation, sonographic assessment of cardiac activity and presence of pericardial effusion, and lastly chest decompression).
●Make the anterior thoracotomy incision in the left fourth or fifth intercostal space, enter the chest, and place the retractor. Alternative incisions may be needed to improve anterior mediastinal or right chest exposure. (See 'Make the incision' below and 'Enter the chest' below.)
●Use damage control maneuvers only to manage hemorrhage that impedes performance of pericardiotomy or aortic cross-clamping. (See 'Damage control' below.)
●Open the pericardial sac, if necessary, and use temporizing measures to control any cardiac injuries, if present. Manage air embolism if identified. (See 'Open the pericardium' below and 'Control hemorrhage' below and 'Manage any air embolism' below.)
●Cross-clamp the aorta to allow filling of the heart and facilitate ongoing fluid resuscitation. (See 'Cross-clamp the aorta' below.)
●Initiate open cardiac massage if needed. (See 'Perform open CPR' below.)
●Systematically explore the thoracic structures looking for any additional bleeding or hematoma formation that might suggest underlying injury. (See 'Control hemorrhage' below.)
Make the incision — Anterior thoracotomy is performed by making an incision in the fourth or fifth intercostal space, usually on the left. If massive bleeding from a right chest injury is suspected, then an initially right-sided approach may be taken. A posterolateral thoracotomy approach is not used in emergency circumstances because of the need to position the patient in a lateral decubitus position [39]. For patients who arrive in the emergency department with an offending penetrating object (eg, knife blade) in situ, the object should generally be left in place, unless it interferes with performing the thoracotomy [40].
A left-sided incision extends from the right lateral border of the sternum to the table to completely expose the heart, lungs, and descending thoracic aorta. The curvilinear skin incision is made boldly with a #10 blade from the margin of the sternum along the intercostal space between the fourth and fifth ribs (fourth interspace), or fifth and sixth ribs (fifth interspace) (figure 5), below the nipple and carried laterally to the left posterior axillary line, following the curve of the rib. In the female patient, the breast should be retracted superiorly. The skin and subcutaneous fat are incised sharply with the scalpel with no attention to attempting hemostasis. In thin patients, the initial incision can be carried directly down to one of the ribs.
If needed, the thoracotomy incision can be extended across the sternum to the right (or left) chest as a bilateral transverse thoracosternotomy or "clamshell thoracotomy," using a Lebsche knife, Gigli saw, or trauma shears [41,42]. The clamshell incision (figure 6) greatly improves access to the anterior mediastinum, aortic arch, and great vessels. In the event of return of circulation, the internal mammary arteries should be controlled to minimize hemorrhage. In the author's experience, the extension of the thoracotomy across the sternum occurs in most patients felt to have potentially survivable injuries as it provides excellent exposure.
Enter the chest — Enter the thoracic cavity laterally (away from the heart) by making a small (1 to 2 cm) incision along the superior margin of the underlying rib to avoid injury to the intercostal neurovascular bundle, which is located along the inferior margin of the rib. Divide the pleura immediately beneath the muscles taking care to not injure the lung. Once the chest is entered, place a curved Mayo scissors (or sterile trauma shears) into the wound and push anteriorly toward the sternum and then posteriorly toward the bed to open the interspace by shearing the intercostal muscles from the superior margin of the rib. Some surgeons prefer to disrupt the intercostal muscles with a sweeping motion by placing one or two fingers of each hand into the initial defect.
After entering the chest, insert a rib spreader (Finochietto) between the ribs with the handle of the retractor directed toward the left axilla (figure 5), permitting extension of the incision across the sternum for additional exposure, if necessary, without the need to replace the retractor. The retractor should be opened as wide as possible to maximize exposure. To avoid rib fracture, some surgeons may intentionally divide one or more of the ribs posteriorly as far as possible or divide cartilage anteriorly. This "shingling" provides superior access with decreased risk of injury to the operator from rib fragments.
As the chest is being opened, the endotracheal tube should be advanced to achieve right mainstem intubation. This collapses the left lung and often allows for better exposure for the aorta and pericardium.
Damage control — Any obvious bleeding source should be controlled with direct pressure initially. Bleeding that will hinder pericardiotomy or aortic cross-clamping needs to be managed first. Bleeding from noncardiac sites can be controlled using a combination of direct pressure using laparotomy pads or sponge sticks. Even for experienced trauma surgeons, blind placement of clamps to control bleeding can be hazardous and clamps should only be used as a last resort.
Significant hemorrhage originating from the pulmonary parenchyma or major pulmonary vasculature can be controlled with direct clamping of the injured lung tissue (Duval clamp) or vessel, clamping the pulmonary hilum, or by using the "pulmonary hilar twist" maneuver (figure 7) [43]. Pulmonary hilar clamping and the "pulmonary hilar twist" also reduce the potential for air embolism. However, the pulmonary hilar twist can result in significant irreversible injury to the lung and great vessels and should be a maneuver of last resort.
To perform hilar clamping or the "pulmonary hilar twist":
●Mobilize the injured lung hilum by first dividing the inferior pulmonary ligament to the level of the inferior pulmonary vein (figure 7). Inadvertent injury to the inferior pulmonary vein is a major iatrogenic complication that must be avoided, as it is often fatal.
●Control the hilum of the lung with a large vascular clamp (eg, Crawford or Satinsky) or by using a Rommel tourniquet and snares [44].
●For the pulmonary twist maneuver, rotate the lower lobe anteriorly up over the upper lobe twisting the lung clockwise 180°, which compresses the main pulmonary artery and vein against the bronchus [43]. Avoid extending or creating new injuries by overtwisting.
●Place laparotomy packs at the base and apex of the lung to prevent the lung from untwisting.
●Terminate the maneuver by reversing the above steps as quickly as possible after hemorrhage is controlled.
Prolonged hilar control (clamp or twist) can lead to complications such as right heart failure, dysrhythmias, hypoxemia, and pulmonary infarction [45,46]. As such, the duration of time the hilum is clamped or twisted should be minimized, and pulmonary injuries identified and definitively managed as soon as is possible. Prolonged hilar control may commit the patient to pneumonectomy. In these patients, the hilum should remain clamped or twisted until pulmonary resection can be performed.
Open the pericardium — The next step in a resuscitative thoracotomy is pericardiotomy. If there is no pericardial tamponade and other obvious noncardiac injuries are apparent, the pericardium should be left intact to address these injuries first. Open cardiac massage can be performed with the pericardium intact. Unintentional injury to the myocardium, coronary arteries, or phrenic nerve can be a consequence of entry into the pericardial sac. The phrenic nerve is identified on the anterolateral surface of the pericardium and should be protected from injury (figure 8). (See 'Thoracic anatomy' above.)
A variety of techniques have been proposed to achieve safe and rapid initial entry into the pericardial sac.
●The Advanced Surgical Skills for Exposure in Trauma (ASSET) course recommends carefully opening the pericardium with a controlled incision using a knife anterior to the phrenic nerve [47].
●Others have suggested using toothed forceps, if available, to first grasp the pericardium anterior to the phrenic nerve to lift it up prior to carefully incising it with a knife or scissors (picture 2).
The return of clear pericardial fluid indicates there is no need to open the pericardium any further. If tamponade is present, the initial decompression through a relatively small pericardiotomy may be enough to restore cardiac output sufficiently for the patient to be transported to the operating room for further care in more optimal conditions. If this is not the case, or if severe hemorrhage needs control, a more complete pericardiotomy is performed. In this circumstance, proceed as follows:
●Use a Metzenbaum scissors to extend the incision cranial and caudally well away from and parallel to the phrenic nerve.
●Control any bleeding initially with gentle digital pressure. (See 'Control hemorrhage' below.)
●With the heart and great vessels exposed, if needed, partially deliver the heart from the pericardial sac for inspection and possible intervention. Care must be taken to avoid extensive displacement that may impede right heart filling and induce ventricular fibrillation or asystole.
Cross-clamp the aorta — Cross-clamping the thoracic aorta redistributes the available intravascular blood volume to the heart and brain, and effectively doubles the mean arterial pressure and cardiac output [1,48-54]. For patients with concomitant abdominal or lower extremity injuries, cross-clamping also reduces blood loss.
Initial manual aortic compression provides a quick means by which to reduce distal blood flow to allow resuscitation while additional dissection for cross-clamp placement is done.
To perform aortic cross-clamping:
●Retract the left lung superiorly.
●Divide the inferior pulmonary ligament.
●Palpate the orogastric or nasogastric tube (if present) to differentiate the esophagus from the empty descending aorta.
●Perform the periaortic dissection at the level of an intervertebral space in a plane perpendicular to the aorta to avoid injury to intercostal vessels, which branch from the aorta at the level of the mid-vertebral body (figure 9).
●Incise the parietal pleura overlying the aorta and separate the tissues between the aorta and esophagus, as well as the prevertebral fascia to create sufficient space to place the aortic clamp without avulsing the intercostal arteries from the posterior surface of the aorta.
●The aorta should be cross-clamped at the most distal location that is practical to preserve spinal cord blood supply.
●To avoid prolonged clamping (more than 30 minutes) proximal to the visceral vessels, reposition the thoracic aortic cross-clamp lower on the abdominal aorta as soon as possible in patients with abdominal injuries who survive the initial emergency resuscitative efforts. (See "Surgical and endovascular repair of ruptured abdominal aortic aneurysm", section on 'Aortic control'.)
Perform open CPR — Continue Advanced Trauma Life Support (ATLS) and Advanced Cardiac Life Support (ACLS) protocols with open cardiac massage and internal defibrillation, as needed. If the pericardium was not opened, open cardiac massage can be performed with the pericardium intact.
Cardiac massage should be started immediately after placement of the thoracic aortic clamp and should only be delivered with a two-hand ("clapping") technique (figure 10).
●Place the wrists together at the apex of the heart.
●Squeeze the heart between the two open palms in a rhythmic motion.
●Maintain the thumb of each hand adjacent to the index finger to avoid inadvertent digital penetration into the heart. The pulmonary outflow tract is particularly vulnerable to accidental puncture with the thumb.
For maintaining cardiac output and providing cerebral and coronary perfusion, open cardiac massage is superior to closed chest compressions in animal studies [55-58]. External compressions provide approximately 25 percent of baseline cardiac output, resulting in only 10 percent of normal cerebral and coronary flow, whereas open cardiac massage generates 60 to 70 percent of baseline cardiac output [56,59]. In a small study of 10 patients all of whom underwent closed chest compressions followed by open chest cardiac massage, coronary perfusion pressures were 400 percent greater with open cardiac massage [60]. However, the use of resuscitative thoracotomy with endovascular balloon occlusion of the aorta for zone 1 aortic occlusion with closed chest compression may be equivalent [61].
For patients in ventricular fibrillation, perform internal cardiac defibrillation with the defibrillator initially set at 10 joules. Repeat defibrillation is performed, as needed, at 10 to 50 joules. Place one of the internal paddles on the anterior (ventral) surface of the heart and place the other on the posterior (dorsal) surface of the heart. As with external defibrillation, all personnel should be well away from the patient prior to defibrillation to prevent inadvertent electric shock and avoid blood splatter.
Control hemorrhage — Control bleeding in a systematic fashion first by identifying and controlling bleeding from the heart, followed by controlling bleeding from major vascular structures of the chest and lungs. Institute temporizing measures until definitive repair can be undertaken in the operating room in which adequate lighting, proper instrumentation, magnification, supplies, and appropriate nursing and support staff are available. (See 'Definitive management' below.)
Patients who are most likely to be saved with a resuscitative thoracotomy are those with stab wounds to the right heart [62,63]. The extent to which repair might be undertaken depends upon the experience of the operator.
Bleeding from cardiac injuries — Direct digital pressure is usually effective at controlling bleeding from cardiac injuries while fluid resuscitation takes place and arrangements are being made for definitive repair by a cardiac, vascular, or trauma surgeon. This is preferred to attempting surgical repair under suboptimal conditions. While the successful use of surgical staplers to close cardiac injuries has been reported, in our experience, their use is more likely to cause further injury. Similarly, while the insertion of a Foley catheter into cardiac wounds has been anecdotally reported to be effective at controlling selected cardiac injuries, inadvertent withdrawal of the inflated balloon may worsen the injury.
Direct surgical repair of cardiac injuries should generally only be undertaken by clinicians with appropriate training and skill. If there is no alternative, suture repair of ventricular cardiac injuries can be accomplished in the emergency department using double-armed polypropylene (eg, 3-0 Prolene), preferably on a cardiovascular (CV) needle. Interrupted sutures are placed in a horizontal mattress fashion with pledgets. The suture is passed into the cardiac tissue on each side of the hole parallel to the finger that is providing vascular control (z-stitch) (figure 11). As the finger is carefully withdrawn, an assistant gently pulls up on the suture, crossing the ends. Additional sutures are placed, as needed, prior to tying the sutures. Venous and atrial wounds can be repaired in a simple, running fashion using 3-0 or 4-0 sutures. (See "Management of cardiac injury in severely injured patients", section on 'Surgical management'.)
If larger defects are present and prove difficult to control or repair with other techniques, as a last resort, balloon occlusion can be tried to achieve temporary hemostasis. A clamped, deflated bladder catheter (5 cc balloon) can be inserted through the cardiac defect, inflated, and then withdrawn to allow the balloon to tamponade the bleeding. Strict attention must be directed to maintaining only enough tension to control bleeding. Too much back pressure will pull the inflated catheter through the defect and create a more catastrophic injury. The catheter can also be used for rapid infusion of warmed resuscitation blood and fluid directly into the cardiac chamber.
Other bleeding sites — Following evaluation and management of any cardiac injuries, attention should be directed toward any remaining bleeding sites in the chest cavity that have not already been temporarily controlled using damage control techniques. In penetrating trauma, missile or implement trajectories are followed, looking for great vessel, lung parenchyma, chest wall, and diaphragmatic injuries. Vascular and pulmonary injuries can be clamped, or direct pressure applied to control bleeding. Laparotomy pads that have controlled bleeding should remain in place until definitive repair can be undertaken in the operating room under optimal circumstances. (See 'Damage control' above.)
Manage any air embolism — After opening the chest and pericardium, the presence of air in the coronary vessels, heart, and possibly the aorta is diagnostic for air embolism. This occurs either by entrained venous/right-sided air passing through a right-to-left shunt or from a broncho-pulmonary venous fistula following injury.
Initial treatment of air embolism focuses on preventing any additional air from entering the circulation, reducing the volume of air that is present with aspiration, and providing ongoing hemodynamic support [64-66].
For venous embolism, Trendelenburg positioning, occlusion of the open vessels where air may be entraining, volume repletion to raise venous pressure, and aspiration of the right ventricle are used.
Arterial air can cause catastrophic injury to the brain and heart. The "vapor lock" acute occlusion of coronary and cerebral vessels causes pump failure and stroke, respectively, secondary to ischemia. Cardiac bypass or other support may be necessary. There are reports of endovascular catheter-based aspirations for iatrogenic arterial air embolism, but these are impractical in the trauma setting. Hilar cross-clamp to prevent further air through the fistula is done as soon as the process is recognized. (See "Overview of blunt and penetrating thoracic vascular injury in adults", section on 'Management of specific vascular injuries'.)
DEFINITIVE MANAGEMENT —
If the patient regains signs of life because of resuscitative thoracotomy, the next priority is immediate transfer to the operating room for definitive management by a multidisciplinary trauma team (trauma surgery, cardiac surgery, thoracic surgery, vascular surgery). Given the need for this level of expertise, resuscitative thoracotomy should not be undertaken in any emergency department where definitive injury management is not immediately available. (See 'Requirements for successful thoracotomy outcomes' above.)
Detailed management of specific injuries is beyond the scope of this topic but can be found in separate topic reviews.
●Chest trauma:
•Heart – (See "Management of cardiac injury in severely injured patients".)
•Great vessels and thoracic aorta – (See "Overview of blunt and penetrating thoracic vascular injury in adults" and "Management of blunt thoracic aortic injury" and "Surgical and endovascular techniques for aortic arch branch and upper extremity revascularization".)
•Lungs – (See "Overview of pulmonary resection".)
●Abdominal trauma:
•Vascular injury – (See "Abdominal vascular injury".)
•Solid organ injury – (See "Surgical techniques for managing hepatic injury" and "Surgical management of splenic injury in the adult trauma patient" and "Management of blunt and penetrating kidney trauma".)
•Pelvic trauma – (See "Severe pelvic fracture in the adult trauma patient".)
Once thoracic, abdominal, or other injuries have been adequately addressed in the operating room, the question remains whether to close the chest or to perform temporary closure, as is often performed following damage control laparotomy for trauma. Temporary closure associated with damage control procedures is associated with higher mortality and complications than conventional closure. Lacking prospective studies, this signal is likely due to selection and survival bias as only the most critically injured patients with the most deranged physiology undergo this closure. There is little to no evidence that the technique itself is harmful [67-69].
Patients who survive the initial operation are transferred to the intensive care unit for ongoing resuscitation to correct acidosis, coagulopathy, and hypothermia with formal sternal closure once physiologic resuscitation has been successful. (See "Ongoing assessment, monitoring, and resuscitation of the severely injured patient" and "Surgical management of sternal wound complications", section on 'Management of the open sternum'.)
SURVIVAL AND FUNCTIONAL OUTCOMES
Survival — The available data evaluating the outcomes of resuscitative thoracotomy are derived from retrospective reviews and case series. Compared with the early experience, more contemporary studies report higher survival rates, even for patients with blunt injuries [2,9,22,32,70-88]. When evaluating mortality rates, confounders such as the type of available prehospital care and whether patients who died at the scene were included in the analysis should be considered [89]. In a systematic review that included 53 studies, the most important predictors of survival were a shockable initial cardiac rhythm or the presence of cardiac motion on ultrasound. Mechanism of injury was not associated with either return of spontaneous rhythm or survival [90].
Studies are generally of low quality with heterogeneity in the populations and outcomes studied. A systematic review of 24 nonrandomized studies identified 4620 resuscitative thoracotomies [32]. The overall survival rate was 7.4 percent, ranging from 2.5 to 27.5 percent. The most significant factors associated with survival included the presence of signs of life, mechanism of injury, and magnitude and location of the injury. In a later review that included 10,238 patients who underwent resuscitative thoracotomy, 8.5 percent survived to discharge and 86 percent of survivors were neurologically intact [3].
By mechanism and severity of injury — Mechanism of injury is an important factor determining survival following resuscitative thoracotomy. In a meta-analysis performed by the American College of Surgeons Committee on Trauma, which included 7035 patients with emergency department thoracotomy (EDT), the overall survival rate was 7.8 percent [91]. Stratified by mechanism of injury, patients with penetrating injuries had a survival rate of 11.2 percent, compared with 1.6 percent in those with blunt trauma. Among penetrating injuries, survival following resuscitative thoracotomy for stab wounds is two to four times higher (up to 70 percent) compared with gunshot wounds [32,62,63,80,88,92,93].
The location and magnitude of the injuries also plays an important role in determining survival.
●One review reported the highest survival rates for isolated penetrating cardiac injuries (19 percent), followed by penetrating noncardiac thoracic (11 percent), penetrating abdominal (4 percent), and multiple penetrating injuries (less than 1 percent) [32]. Patients with blunt injuries had a survival rate of 1.4 percent. Overall survival for thoracic injuries was 10.7 percent compared with 4.5 percent for abdominal injuries, and much less for multiple injuries at 0.7 percent. A later review of 2012 patients noted a survival rate of 19.9 percent with penetrating injuries (45.6 stab versus 18.7 percent gunshot) and 7.6 percent for blunt injuries [88].
●For patients with severe penetrating abdominal injuries who underwent thoracic aortic clamping prior to abdominal exploration, retrospective reviews report survival rates ranging from 14 to 42 percent [48,49,94,95]. In one of these reviews, hemorrhagic shock was due to major abdominal vascular (75 percent) or severe liver (25 percent) injuries, and all required massive blood transfusion [95]. Sixteen percent of the patients survived hospitalization neurologically intact.
By physiologic signs — Survival is rare in the absence of witnessed vital signs at the scene or in the emergency department. Survival is also closely related to the duration of cardiopulmonary resuscitation (CPR) prior to thoracotomy. Survival is extremely rare if CPR exceeds 15 minutes.
The absence of signs of life, which refers to lack of any evidence of cardiac and cerebral perfusion, is associated with a poor prognosis [81,96,97]. One retrospective review of 102 patients undergoing thoracotomy over a 25-year period identified an overall survival rate of 7.8 percent [82]. The patient population was stratified by the Lorenz Physiologic Status Classification based upon vital signs and signs of life as follows [98]:
●Class I – No signs of life
●Class II – Agonal (ie, pulseless electrical activity, no blood pressure)
●Class III – Profound shock (ie, blood pressure [BP] <60 mmHg)
●Class IV – Mild shock (ie, 60 <BP <90 mmHg)
Survival rates were reduced for lower physiologic status. Survival was 0.7 percent in class I patients, improving to 44.4 percent in class IV patients [82].
Patients with documented vital signs (blood pressure, pulse) in the field but who arrive to the emergency department in cardiac arrest have higher survival rates (12 to 19 percent) compared with those without vital signs (0 to 4 percent) [3,32,82-84,88,96,99].
●In a systematic review involving 10,238 patients who underwent resuscitative thoracotomy in the emergency department, patients presenting pulseless after penetrating thoracic injury had the most favorable outcomes both with and without signs of life (with, survival/neurologically intact: 21.3/11.7 percent; without, survival/neurologically intact: 8.3/3.9 percent) [3].
●For patients presenting pulseless after penetrating extrathoracic injury, outcomes were more favorable with signs of life compared to without (with, survival/neurologically intact 15.6/16.5 percent; without, survival/neurologically intact 2.9/5 percent).
●In a review of the Trauma Quality Improvement Program database, in addition to no signs of life at arrival in the emergency department, not surprisingly, pulse was a significant independent predictor of mortality (prehospital pulse <60 beats per minute: odds ratio 3.43, 95% CI 1.73-6.79; emergency department pulse <60 beats per minute: odds ratio 4.70, 95% CI 2.47-8.94) [88].
The need for CPR in the field is also associated with low survival rates. Although CPR in the field portends a poor prognosis, CPR in the presence of cardiac tamponade has a more favorable outcome, particularly among patients with stab wounds [100]. For patients with blunt trauma, CPR in the field is associated with no meaningful survival; any survivors are not likely to be neurologically intact [76,100]. For patients with penetrating injuries, survival is possible if the total time for CPR in the field is brief (<15 minutes).
Outcomes after pulseless blunt injury patients are poor. Survival following blunt trauma without neurologic deficit is rare if CPR exceeds 10 minutes. A prior review of resuscitative thoracotomy after blunt trauma identified only two survivors from more than 500 patients without signs of life at the scene, and both had severe neurologic deficits [9]. The survival without neurologic deficit if vital signs were lost during transit was 1.8 percent, and if vital signs were present in the emergency department, 4.5 percent. In a series of over 2000 thoracotomy patients, among patients who arrived without signs of life after blunt trauma, there were no survivors [88].
Neurologic outcomes — Approximately one in five survivors of resuscitative thoracotomy have a significant neurologic injury [22,32,76,77,79,85,101]. In the systematic review discussed above, 7 percent of the patients who survived were neurologically impaired [32]. A later database review from the Western Trauma Association reported that 18 percent of survivors had moderate-to-severe neurologic deficits requiring long-term care placement [77]. In a study that examined the clinical condition of the patient upon arrival, neurologically intact survival following resuscitative thoracotomy occurred in fewer than 5 percent of those who arrived to the emergency department in shock, 1 percent for those without vital signs, and 0 percent for those without signs of life in the field [84].
A single-center report from an urban Level I trauma center identified 37 survivors from 448 emergency department thoracotomies. The report suggested that despite the need for prolonged hospitalization and rehabilitation, many survivors of EDT can expect to return to normal functional lives. The average length of stay was 43±41 days, and one-third of patients required extended treatment in a rehabilitation hospital or skilled nursing facility. Multidisciplinary outpatient assessment after a median of 59 months following resuscitative thoracotomy showed that 75 percent had normal cognition and returned to normal activities, 81 percent were freely mobile and functional, and 75 percent had no evidence of posttraumatic stress disorder [102].
Long-term outcomes of survivors — Long-term outcomes of survivors of resuscitative thoracotomy are not well known. In one report, among patients admitted to the intensive care unit following successful resuscitative thoracotomy, only 28 of 96 patients (29 percent) survived to hospital discharge. Fourteen were discharged home, nine to a rehabilitation facility, one to hospice, one to a nursing facility, and two to custody [103]. On followup, 20 were living independently. In a long-term review, among those that could be contacted, the majority of survivors had no evidence of cognitive functional or psychological long-term impairment over a median 59 months follow-up [102].
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General issues of trauma management in adults" and "Society guideline links: Thoracic trauma".)
SUMMARY AND RECOMMENDATIONS
●Resuscitative thoracotomy – Resuscitative thoracotomy is a procedure of last resort in the management of patients with major trauma. It is performed in patients with penetrating or blunt thoracic or exsanguinating abdominal injury who are in extremis, but only under specific clinical circumstances, and only if appropriate resources are available for definitive injury management. (See 'Introduction' above and 'Indicators of futility' above.)
●Control of noncompressible torso hemorrhage – Whether to perform immediate resuscitative thoracotomy, resuscitative thoracotomy with endovascular balloon occlusion of the aorta (REBOA) placement, or to discontinue resuscitative efforts is based on the suspected injuries, loss of vital signs, time since loss of vital signs, the availability of required resources, and the expertise of the resuscitation team. REBOA can be considered for patients with actual or impending traumatic cardiac arrest using the same indications as with resuscitative thoracotomy but without a thoracic source of hemorrhage or tension physiology. (See 'Noncompressible torso hemorrhage' above and 'Decision for resuscitative thoracotomy or REBOA' above.)
●Preparation – Once the decision has been made to open the chest, one member of the trauma team should be designated to lead the ongoing resuscitation effort while the senior member of the trauma team is performing the thoracotomy. Given the potential for blood splatter and the prevalence of bloodborne disease in the trauma population, all personnel involved in the care of the trauma patient should observe universal precautions wearing gowns, gloves, and eye protection at all times. (See 'Preparation' above.)
●Procedural steps – The procedural steps are generally performed in a defined order; however, the clinical presentation of the patient or the nature of specific injuries may make one step take precedence over another. The typical approach is as follows:
•Stop external chest compressions prior to thoracotomy. Ongoing chest compressions may delay or complicate the most critical aspects of resuscitation (ie, establishment of intravenous access, endotracheal intubation, sonographic assessment of cardiac activity and presence of pericardial effusion, and lastly, chest decompression).
•Make the incision in the fourth intercostal space, enter the chest, and place the retractor. (See 'Make the incision' above and 'Enter the chest' above.)
•Use damage control maneuvers to manage hemorrhage that impedes the performance of pericardiotomy or aortic cross-clamping. (See 'Damage control' above.)
•Open the pericardial sac, and use temporizing measures to control any cardiac injuries, if present. Manage air embolism if identified. (See 'Open the pericardium' above and 'Control hemorrhage' above and 'Manage any air embolism' above.)
•Cross-clamp the aorta to allow the filling of the heart and facilitate ongoing fluid resuscitation. (See 'Cross-clamp the aorta' above.)
•Initiate open cardiac massage if needed. (See 'Perform open CPR' above.)
•Systematically explore the thoracic structures looking for any additional bleeding or hematoma formation that might suggest underlying injury. (See 'Control hemorrhage' above.)
●Survival – Survival following resuscitative thoracotomy is consistently better in patients with penetrating thoracic injury compared with those who have blunt injury. Survival also depends upon the clinical status of the patient prior to arrival in the emergency department, approaching 0 percent for those who do not have signs of life or vital signs in the field. Of those who survive, permanent neurologic deficits occur in 7 to 18 percent of patients. (See 'Survival and functional outcomes' above.)
