Emergency Resuscitative Thoracotomy (ERT)

Algorithm Steps

1. ▶

   Start

   Trauma Patient in Extremis/Arrest

   Patient in cardiac arrest or peri-arrest from trauma

   1. ◆

      Decision

      Signs of Life (SOL)?

      Present at any point

      • Signs of life include:
      • Pupillary response
      • Spontaneous movement
      • Organized ECG activity
      • Measurable BP or pulse
      • Respiratory effort
      1. ◆

         Decision

         Mechanism of Injury?

         Penetrating vs Blunt

         1. ◆

            Decision

            Penetrating Injury Location

            Cardiac vs Non-cardiac thoracic

            1. ◆

               Decision

               Penetrating Cardiac

               Time since SOL lost?

               • Highest survival rates
               • Survival: 8-35%
               • ERT INDICATED if SOL lost <15 minutes
               1. ⚠

                  Warning

                  ERT INDICATED

                  Proceed with thoracotomy

                  • Left anterolateral thoracotomy
                  • 5th ICS, from sternum to posterior axillary line
                  • Can extend to clamshell if needed
                  1. ●

                     Action

                     ERT Procedure Steps

                     Systematic approach

                     • 1. Left anterolateral thoracotomy (5th ICS)
                     • 2. Open pericardium longitudinally (anterior to phrenic)
                     • 3. Evacuate clot, repair cardiac wounds
                     • 4. Cross-clamp descending aorta if needed
                     • 5. Internal cardiac massage
                     • 6. Extend to clamshell for right-sided access
                     1. ●

                        Action

                        Cardiac Injury Management

                        Temporize and repair

                        • Digital occlusion of wound
                        • Skin stapler for rapid closure
                        • Horizontal mattress with Teflon pledgets
                        • Foley catheter balloon tamponade (last resort)
                        • Avoid coronary arteries
                        1. ◆

                           Decision

                           ROSC Achieved?

                           Return of spontaneous circulation

                           1. ✓

                              Outcome

                              Transport to OR

                              ROSC achieved - definitive repair

                           2. ✓

                              Outcome

                              Terminate Resuscitation

                              No ROSC despite appropriate interventions

                     2. ●

                        Action

                        Aortic Cross-Clamp

                        For distal hemorrhage control

                        • Clamp descending thoracic aorta
                        • Increases coronary and cerebral perfusion
                        • Controls subdiaphragmatic hemorrhage
                        • Remove clamp when able, limit ischemia time
               2. ●

                  Action

                  ERT Contraindicated

                  Terminate resuscitation

                  • SOL lost >15 min (penetrating) or >10 min (blunt)
                  • Blunt arrest without cardiac injury
                  • Massive non-survivable injuries
                  • Asystole without prehospital CPR
            2. ◆

               Decision

               Penetrating Non-Cardiac Thorax

               Time since SOL lost?

               • Survival: 10-15%
               • ERT INDICATED if SOL lost <15 minutes
         2. ◆

            Decision

            Blunt Injury

            Cardiac vs Non-cardiac

            1. ◆

               Decision

               Blunt Cardiac

               Time since SOL lost?

               • Lower survival: 1-2%
               • Consider if SOL lost <10 minutes
               • May have survivable injury (tamponade)
            2. ⚠

               Warning

               Blunt Non-Cardiac

               ERT generally NOT indicated

               • Survival <1%
               • ERT NOT recommended
               • Exception: witnessed arrest with organized rhythm