Circulation - Thoracotomy (resuscitative)
We recommend a clamshell approach to maximise access to the thoracic cavity
Experienced surgical providers may prefer a left lateral approach
Cardiac arrest with loss of output for <15 minutes
Penetrating trauma to chest or epigastric injury
Blunt trauma with confirmed or suspected cardiac tamponade
Contraindications (absolute in bold)
Consent is not required
Neurovascular and visceral injury (phrenic nerve, large vessels, heart, lungs)
PPE: gloves and gown, surgical mask, eye protection
Procedural clinician (two preferred) and assistant
Resuscitation team (for airway and arrest management)
Rib spreader (useful if available)
Gigli saw (occasionally required)
Patient supine with both arms abducted at right angles
Confirm traumatic cardiac arrest
Simultaneously control external haemorrhage, oxygenate (LMA or ETT) and ongoing transfusion
Perform bilateral thoracostomies (ceasing procedure if resulting in return of spontaneous circulation)
Cut skin and subcutaneous tissue along fifth intercostal space connecting the thoracostomies
Cut through all layers of the intercostal muscles using trauma shears (from thoracostomy to sternum)
Cut through the sternum using the trauma shears (if unsuccessful proceed to using the Gigli saw)
Open the thoracic cavity using an assistant (or rib spreaders)
Grasp and lift the pericardium using forceps
Make a 10cm anterior midline longitudinal incision using scissors avoiding the phrenic nerve (running laterally)
Remove blood clot from pericardium and deliver heart out of the pericardium
Inspect the heart for any lacerations ensuring to view all surfaces
If cardiac laceration is present occlude the wound using digital occlusion
If closure for transport is required apply interrupted staples to wound
Compress the descending aorta against vertebral column with fingers or closed fist
Consider internal cardiac massage (two-hand technique)
Consider administering intravenous adrenaline to stimulate cardiac activity
If ROSC, control bleeding from internal mammary and intercostal vessels with artery forceps
If no ROSC, cease resuscitation after adequate volume resuscitation
Analgesia, sedation and intubation
Warm blood product resuscitation
Cephazolin 2g IV
Transfer theatre for definitive repair
Document (completion, technique, complications)
Thoracotomy is primarily treating pericardial tamponade as the cause of death
The perceived time of cardiac arrest may not be the time circulation ceases
Consider the possibility of low-flow states with apparent pulseless electrical activity arrest while considering the procedure
Emergency department resuscitative thoracostomy is not a simple procedure. Identifying specific structures in a chest cavity full of blood and addressing reversible pathology is formidable.
While experienced surgical providers may be comfortable with a left lateral approach (reducing morbidity and complications) our opinion is that emergency physicians will have better results with the increased simplicity and working space of a clamshell approach.
Similarly, while experienced surgeons may be able to treat different pathologies in the chest, our opinion is that emergency physician thoracotomy is primarily a procedure to find and treat cardiac tamponade. Tamponade is much more common in penetrating trauma, hence ultrasound confirmation of pericardial fluid is not required. In blunt trauma cardiac tamponade is rare, thoracotomy is not indicated unless this is suspected, or pericardial fluid is confirmed on ultrasound.
Acting quickly to perform the procedure following cardiac arrest is imperative. A favourable outcome is rarely possible (even in penetrating trauma) if thoracotomy is initiated more than 10 minutes after the onset of cardiac arrest.
Asepsis is not required for resuscitative thoracotomy. The risk of infection is insigniﬁcant compared to the increased risk of further tissue hypoxia with any delay to the procedure. A high standard of PPE is required and providers should be aware of a high risk of sharps injury.
This guideline has been reviewed and approved by the following expert groups:
Emergency Care Institute
Greater Sydney Area Helicopter Emergency Service
Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.
Australian Resuscitation Council and New Zealand Resuscitation Council. ANZCOR guideline 11.10.1 – management of cardiac arrest due to trauma. Melbourne: Australian Resuscitation Council and New Zealand Resuscitation Council; 2016. 11pp. Available from https://resus.org.au/guidelines/
Ambulance Service of NSW. Traumatic cardiac arrest. Report HELI.CLI.06. Sydney: ASNSW; 2013. 6pp. Available from: https://sydneyhems.com/resources/policies-and-procedures/
Royal Melbourne Hospital. Emergency department thoracotomy guideline. 2011 Sept (updated 2018 Nov). Available from: https://www.thermh.org.au/sites/default/files/media/documents/clinical/Emergency%20Department%20Thoracotomy%20Guideline.pdf
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