Emergency Medicine Hub / Procedures & Anesthesia • 3 min read • 2 sections

Emergency Resuscitative Thoracotomy (ED Thoracotomy)

Comprehensive emergency evaluation and protocolized surgical execution of Emergency Department Resuscitative Thoracotomy (EDRT/EDT): evidence-based EAST guidelines for survival indications (penetrating chest trauma with signs of life within 15 minutes vs. blunt trauma with signs of life within 5 minutes; CPR duration cutoffs), the left anterolateral thoracotomy extending to bilateral 'clamshell' thoracotomy, longitudinal anterior pericardiotomy (phrenic nerve preservation), relief of cardiac tamponade, cardiac parenchymal stapling/suturing, internal cardiac massage, and cross-clamping of the descending thoracic aorta.

Resuscitation Quick Actions • First 2 Minutes

High-Acuity

Penetrating Chest Arrest (< 15 min)

EAST Guideline: INDICATED if loss of vitals < 15 min with signs of life (pupillary reflex, spontaneous movement, sinus rhythm on monitor)

Blunt Trauma Arrest (< 5 min)

EAST Guideline: INDICATED ONLY if loss of vitals was witnessed directly in the ED (< 5 min CPR); survival < 1–2%

Clamshell Incision Level

5th Intercostal Space (inframammary fold in males, under breast crease in females) extending from left axilla across sternum to right axilla

Pericardiotomy Direction

Pinch pericardium, make small nick, then cut longitudinally ANTERIOR TO THE PHRENIC NERVE (prevents transecting phrenic nerve)

Descending Aorta Cross-Clamp

Retract left lung superiorly; blunt dissect pleura anterior to spine above diaphragm; apply vascular clamp to descending thoracic aorta

Internal Cardiac Massage

Use two flat hands (palms clapping together from apex to base); NEVER use individual fingers (fingers puncture ventricular myocardium)

Bottom-Line Clinical Pearl

Emergency Resuscitative Thoracotomy (ED Thoracotomy) is a salvage surgical procedure indicated for traumatic cardiac arrest or refractory peri-arrest shock. Survival is dictated by INJURY MECHANISM AND TIMING: (1) Penetrating thoracic trauma with loss of vital signs/arrest < 15 minutes prior to arrival carries a survival rate of 15–35% (highest for stab wounds to the heart). (2) Blunt trauma arrest carries an abysmal survival rate (< 1–2%) and is indicated ONLY if signs of life (pupillary response, spontaneous breathing, cardiac motion on FAST) were witnessed directly in the ED (< 5 minutes of lost vitals). Procedural sequence: (1) Right lateral decubitus positioning, (2) Deep left anterolateral incision across the 5th intercostal space (inframammary crease from sternum to mid-axillary line) extended across sternum with trauma shears to create a full CLAMSHELL THORACOTOMY, (3) Retract ribs with Finochietto retractor, (4) Longitudinal anterior PERICARDIOTOMY (cut anterior to the left phrenic nerve) to release tamponade, (5) Deliver heart, cross-clamp the descending aorta immediately above the diaphragm (diverts 80% of cardiac output to coronary and cerebral vessels), and (6) Perform two-handed internal cardiac massage.

1. Evidence-Based Indications: EAST Guidelines

Emergency Department Resuscitative Thoracotomy (EDRT) is performed to accomplish four physiologic goals: (1) Evacuate cardiac tamponade, (2) Directly control exsanguinating cardiac or intrathoracic hemorrhage, (3) Cross-clamp the descending thoracic aorta to redirect remaining blood volume to the brain and heart, and (4) Perform direct internal cardiac compressions and internal defibrillation.

Injury Mechanism	Duration of CPR/Signs of Life	Survival Rate	EAST Guideline Recommendation
Penetrating Thoracic Trauma	Lost vital signs/CPR < 15 minutes with witnessed signs of life (pupillary reactivity, spontaneous breathing, carotid pulse, or cardiac motion on FAST)	15% to 35% (highest for cardiac stab wounds, ~30–35%; gunshot wounds ~10–15%)	STRONGLY RECOMMENDED. Rapid release of tamponade and cardiorrhaphy is lifesaving.
Penetrating Extrathoracic (Abdominal/Extremity)	Lost vital signs/CPR < 5 to 10 minutes with witnessed signs of life	2% to 5%	CONDITIONALLY RECOMMENDED. Serves primarily as an access point to cross-clamp the descending thoracic aorta for proximal vascular control of subdiaphragmatic exsanguination.
Blunt Trauma	Witnessed arrest DIRECTLY IN THE ED (< 5 minutes of CPR) with signs of life present on arrival	< 1% to 2%	CONDITIONALLY RECOMMENDED only for in-ED arrest. If blunt trauma arrest occurred in the field prior to ED arrival, EDRT is universally futile and strictly NOT RECOMMENDED.

2. Stepwise Surgical Execution: The Clamshell Thoracotomy

Surgical Phase	Surgical Action & Anatomical Plane	Instruments & Critical Pitfalls
Phase 1: Left Anterolateral Incision	Intubate and place patient supine. Make a bold, deep incision across the 5th intercostal space (inframammary fold, beneath the nipple in males or along the inframammary crease in females) starting at the sternal border and extending to the mid-axillary line.	#10 scalpel cutting directly through skin, subcutaneous fat, pectoralis, and serratus anterior onto the ribs. Enter intercostal space with Mayo scissors hugging the SUPERIOR BORDER of the 6th rib (avoids intercostal neurovascular bundle).
Phase 2: Extension to Clamshell	If cardiac injury or right-sided pathology is present: extend the incision across the sternum using heavy trauma shears or Gigli saw, continuing into the right 5th intercostal space (Bilateral Clamshell Thoracotomy).	Provides massive, unhindered 360-degree exposure to both hemithoraces, the entire pericardium, hilum, and great vessels.
Phase 3: Pericardiotomy	Insert Finochietto retractor with handle facing axilla; spread ribs. Identify the pericardium. Pinch the pericardium with forceps/fingers, make a small nick, then extend the incision longitudinally from apex to base ANTERIOR TO THE PHRENIC NERVE.	Releases pericardial tamponade; blood and clots burst forth under pressure. Cutting posterior to the phrenic nerve transects the nerve, causing permanent diaphragmatic paralysis.
Phase 4: Cardiorrhaphy & Aortic Cross-Clamping	Deliver the heart. For myocardial lacerations: control with digital pressure, skin staples, or 3-0 Prolene horizontal mattress sutures over Teflon felts. Retract left lung superiorly and medially; blunt dissect the pleura anterior to the thoracic spine just above the diaphragm; place a large vascular clamp across the descending thoracic aorta.	Aortic cross-clamping increases coronary and cerebral perfusion pressure by $> 300\%$. Limit cross-clamp time to $< 30\text{ minutes}$ to prevent spinal cord ischemic paraplegia and acute renal necrosis.

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