Indications
- Penetrating chest (or upper abdominal) trauma with cardiac arrest or peri-arrest (loss of signs of life) occurring shortly before or on arrival — most guidance frames this as within around 10–15 minutes, with better outcomes the shorter this interval and with witnessed arrest.
- Profound hypotension refractory to resuscitation with a penetrating mechanism, as an adjunct alongside other life-saving measures — for example to control intrathoracic bleeding or perform internal cardiac massage.
- Blunt traumatic cardiac arrest is a much weaker indication — survival is substantially lower than for penetrating trauma, and the accepted window is much narrower (commonly cited as around 5–10 minutes of CPR, versus up to ~15 minutes for penetrating torso trauma); only consider in a witnessed, very recent arrest with a plausible reversible cause and immediate surgical back-up.
RCEM's position is clear: resuscitative thoracotomy should only be undertaken where there is an immediately available surgical team and onward "chain of survival" — without this, the procedure is likely to be futile even if technically successful.
Futility criteria — when not to proceed
Do not proceed
- Blunt trauma with prolonged CPR and no signs of life since the scene.
- No cardiac output for a prolonged period with asystole and no reversible cause identified.
- No realistic onward surgical pathway (no immediately available theatre/cardiothoracic or general surgical cover) — proceeding without this is very unlikely to result in survival.
Stronger case to proceed
- Penetrating mechanism, witnessed or very recent loss of signs of life, short pre-hospital CPR time.
- Signs of life (pupillary response, organised rhythm, respiratory effort) present at scene or on arrival.
- Immediate access to a surgical team able to continue definitive care.
This is a resource-intensive, high-risk-to-staff procedure (sharps, blood exposure) with a low overall survival rate even in ideal circumstances — the decision to proceed must be made deliberately by the team leader, not by reflex.
Preparation
- Declare the decision to proceed clearly and assign roles: the most experienced operator performs the thoracotomy; others manage airway, access, blood products and documentation.
- Alert theatres/cardiothoracic or general surgery immediately — before, not after, starting the incision.
- Massive haemorrhage protocol activation; give blood products rather than crystalloid where major haemorrhage is likely.
- Full personal protective equipment for all staff — high risk of blood exposure and sharps injury.
- No time for full aseptic technique or consent — this is an immediate life-saving intervention.
Equipment
Scalpel (large blade)
Heavy scissors (trauma/rib shears) or Gigli saw for sternum
Large clamps (Spencer Wells) and rib retractor (Finochietto if available)
Internal defibrillator paddles
Vascular clamps for aortic cross-clamping
Suture material for cardiac wound control
Suction (high volume)
Full PPE for all staff (gown, gloves, eye protection)
Clamshell incision
Step-by-step technique
Bilateral finger thoracostomies
Rapidly create bilateral thoracostomies in the 4th/5th intercostal space, anterior to the mid-axillary line, to exclude/decompress bilateral tension pneumothoraces first.
Join the incisions
Extend each thoracostomy anteriorly with a scalpel/heavy scissors across the chest wall, joining them in the midline to create a single bilateral incision.
Divide the sternum
Cut transversely through the sternum with heavy scissors, rib shears, or a Gigli saw, taking care with the internal mammary vessels at the lateral sternal edges.
Open and retract
Lift the anterior chest wall open like a book/clamshell; insert a rib spreader if available for sustained wide exposure.
Open the pericardium
Incise the pericardium longitudinally, anterior and parallel to the phrenic nerve (which runs along the pericardial surface) — avoid transecting it.
Deliver and control the heart
Deliver the heart if tamponade or a cardiac wound is present; control any cardiac wound with digital pressure, a finger, or a Foley catheter balloon, then suture if trained to do so.
Internal cardiac massage
Perform bimanual or two-handed internal cardiac massage if there is no output, coordinating with the wider resuscitation team.
Aortic control (if indicated)
Cross-clamp the descending thoracic aorta if intra-abdominal haemorrhage is suspected as the source, to redirect blood flow to the heart and brain — a temporising measure pending definitive surgical control.
Avoid the phrenic nerves when opening the pericardium — they run longitudinally on its lateral surface bilaterally; incise anterior and parallel to them, not across.
Aftercare
- If return of spontaneous circulation is achieved, this is only the first step — the patient needs immediate transfer to theatre for definitive surgical control and haemostasis.
- Continue massive haemorrhage protocol and haemodynamic support throughout transfer.
- Full debrief for the team after every resuscitative thoracotomy, given the psychological impact and the value of learning from each case, successful or not.
- Clear, contemporaneous documentation of timings, indication, and findings — important both clinically and medico-legally.
- Offer staff support/wellbeing follow-up — this is among the most psychologically demanding procedures in emergency medicine.
Team & human factors
- Declare the decision to proceed (or not) out loud, with the team leader taking ownership of the call.
- Alert surgical/theatre teams as the first action, in parallel with starting the procedure, not sequentially after.
- Assign a scribe/documenter early — timings and findings are easily lost in the intensity of the resuscitation.
- This is a low-frequency, high-stakes skill — simulation-based training is essential, as very few clinicians will perform it often in real practice.
- Debrief formally afterwards regardless of outcome, covering both clinical and human-factors learning points.
DOPS pointers
RCEM curriculum: Intermediate/Higher Procedural Skill. Given the rarity of real cases, sign-off is typically simulation-based. What assessors look for:
| 1 | Observed only (or simulated) — can describe indications, futility criteria, and the clamshell sequence. |
| 2a | Performs the technique on a simulation model with a supervisor present: correct incision, sternal division, pericardiotomy avoiding phrenic nerves. |
| 2b | Performs the full sequence fluently in simulation including cardiac wound control and internal massage. |
| 3 | Leads the team decision-making on indication/futility in a simulated scenario, coordinates surgical escalation without hesitation. |
| 4 | Independent; leads departmental simulation training and post-event debrief for this procedure. |
References
- Royal College of Emergency Medicine. Position Statement: Resuscitative Thoracotomy in Trauma Units. RCEM, April 2017.
- American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 10th edition, 2018.
- RCEMLearning — Traumatic Cardiac Arrest and resuscitative thoracotomy resources.
- RCEM Curriculum 2021 — Emergency Medicine Specialty Learning Outcomes: intermediate/higher procedural skills (DOPS), major trauma.