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Trauma SurgeryEmergency

Emergency Resuscitative Thoracotomy (ERT)

Emergency Resuscitative Thoracotomy (ERT): Adult trauma: cardiac arrest or peri-arrest → Treat reversible causes now, all at the same time → VF or pulse...

Pathway Overview

21 steps

Algorithm Steps

21 total

  1. 01Start

    Adult trauma: cardiac arrest or peri-arrest

    Pulseless, or systolic BP <60 mmHg despite resuscitation. If time allows before arrest, thoracotomy in theatre is preferred.

  2. 02Warning

    Treat reversible causes now, all at the same time

    They take priority over chest compressions and adrenaline, unless a medical cause is likely. Give compressions at the same time if staff allow. Do not wait for the ERT decision.

    • Control bleeding: direct pressure, tourniquet, pelvic binder
    • Give blood: plasma and red cells 1:1 or 1:2; start massive transfusion protocol
    • Open the airway and ventilate; finger thoracostomy if chest injury (both sides if needed)
  3. 03Warning

    VF or pulseless VT, commotio cordis or medical cause: defibrillate now

    Shock promptly while bleeding, airway and chest are treated. Do not delay the shock for the ERT decision.

    • Commotio cordis (blow to the front of the chest): early defibrillation is the priority
    • Medical cause before the injury (for example collapse while driving): standard adult ALS
    • Shockable rhythm counts as cardiac electrical activity, but defibrillate before ERT
  4. 04Warning

    Pregnancy, child or no trained operator: change the plan

    Check these before the ERT decision.

    • Pregnancy >20 weeks or uterus above umbilicus: call obstetric and neonatal help; manual left uterine displacement; perimortem caesarean delivery
    • Child: use paediatric ERT guidance; criteria differ
    • ERT only in hospital, by a surgeon or trained emergency or critical care doctor; if none, continue trauma arrest care; tamponade: needle pericardiocentesis, ideally ultrasound-guided
  5. 05Decision

    Injuries obviously incompatible with life?

    For example, substantial body disruption. If not, trauma arrest care is not futile: continue.

  6. If Yes
    1. 06Outcome

      Injuries incompatible with life: stop resuscitation

      Resuscitation and ERT are futile.

    If No
    1. 07Decision

      ERT futile? (signs of life, CPR time, ultrasound)

      Yes if any: no signs of life, and CPR 10 min or more after blunt or 15 min or more after penetrating injury; no signs of life or electrical activity only, and ultrasound shows no organised cardiac activity and no tamponade. Signs of life: pupil response, breathing, pulse or BP, movement, cardiac electrical activity.

    2. If Yes
      1. Futile
      2. 08Action

        ERT futile: no ERT; continue trauma arrest care

        Do not stop only because ERT is futile. Tamponade found now does not make ERT indicated.

        • Continue bleeding control, blood, airway and finger thoracostomy
        • Stop if no ROSC 10 min after reversible causes are treated
        • Before stopping, consider hypothermia, toxins and thrombosis
        • Hypothermic arrest: continue CPR and rewarm (ECLS if available); the 10-min stop rule does not apply
      3. 09Decision

        ROSC achieved?

        ROSC: organised cardiac activity with sustained systolic BP >70 mmHg.

      4. If Yes
        1. 10Outcome

          ROSC: to theatre for definitive repair

          Urgent surgical control of bleeding and injuries.

        If No
        1. 11Outcome

          No ROSC: stop resuscitation

          Stop when there is no ROSC 10 min after reversible causes are treated. After ERT: stop if there is still no organised cardiac activity after tamponade, bleeding and air embolism are treated. Before stopping, consider hypothermia, toxins and thrombosis. Hypothermic arrest: continue CPR and rewarm (ECLS if available).

      If No
      1. Not futile
      2. 12Decision

        Not futile: circulation restored with resuscitation?

        ROSC: organised cardiac activity and sustained systolic BP >70 mmHg. No organised cardiac activity but tamponade on ultrasound: go to ERT now.

      3. If Yes
        1. Circulation restored
        2. 13Outcome

          Circulation restored: no ERT; definitive care

          Continue resuscitation and injury-specific management.

        If No
        1. No ROSC
        2. 14Decision

          No ROSC: site of main injury?

          Blunt or penetrating. Chest; abdomen or pelvis; head, neck or limb. Tamponade on ultrasound: ERT at any site.

        3. Chest
        4. 15Action

          Chest injury, blunt or penetrating: perform ERT

          Also for tamponade after injury at any site (WTA 2024). Best chance if ERT starts within 10 min of arrest.

          • Penetrating chest: survival about 21% with signs of life, 8% without (EAST 2015)
          • Blunt: survival about 5% with signs of life, under 1% without (EAST 2015)
          • Blunt with no signs of life: EAST 2015 advises against ERT; WTA 2024 allows it only within 10 min of CPR, with organised cardiac activity or tamponade on ultrasound
        5. 16Action

          ERT: procedure steps

          When ERT is done. Adults, in hospital, by a surgeon or trained emergency or critical care doctor. Non-perfusing rhythm: open cardiac massage and ALS; internal defibrillation for VF. No chest source: look for abdominal, pelvic or limb bleeding.

          • Left anterolateral thoracotomy, 5th intercostal space, with right chest drain; clamshell from the start, or if there is a large right haemothorax or right chest bleeding
          • Large left haemothorax: evacuate, control bleeding, clamp the hilum if needed
          • Open the pericardium lengthwise, anterior to the phrenic nerve; remove blood and clot
          • No tamponade, cardiac injury or organised cardiac activity: treat air embolism if suspected; if still no activity after brief open cardiac massage, stop
          • Organised cardiac activity and systolic BP <70 mmHg: clamp the descending aorta
        6. Tamponade or cardiac wound
        7. 17Action

          Tamponade or cardiac wound: control and repair

          If tamponade or a cardiac wound is found. Move to theatre if ROSC.

          • Finger occlusion of the wound
          • Skin staples or sutures for temporary closure
          • Pledgeted horizontal mattress sutures; avoid the coronary arteries
          • Foley balloon tamponade: last resort, can enlarge the wound
        8. Path rejoins step 09Shared downstream outcome
        9. Persistent hypotension
        10. 18Action

          Aortic cross-clamp: if hypotension persists

          If organised cardiac activity with systolic BP <70 mmHg, or bleeding below the diaphragm.

          • Clamp the descending thoracic aorta above the diaphragm
          • Raises coronary and cerebral perfusion
          • Limits bleeding below the diaphragm
          • Remove as soon as possible to limit ischaemia time
        11. Path rejoins step 09Shared downstream outcome
        12. No cardiac activity, air embolism suspected
        13. 19Action

          Air embolism suspected: control air entry, aspirate the heart

          If there is no organised cardiac activity and air embolism is suspected.

          • Control the site of air entry or clamp the hilum
          • Head down (Trendelenburg)
          • Aspirate air from the ventricles, aortic and pulmonary outflow tracts and coronary arteries
          • Still no organised cardiac activity: stop. Organised activity and systolic BP <70 mmHg: clamp the descending aorta
        14. Path rejoins step 09Shared downstream outcome
        15. Reassess
        16. Path rejoins step 09Shared downstream outcome
        17. Abdomen or pelvis
        18. 20Action

          Abdomen or pelvis injury: ERT with aortic clamp, or zone 1 REBOA

          Tamponade: ERT. REBOA only where available, by trained staff, and if no thoracic aortic injury is suspected.

          • Aim: occlude the aorta to limit bleeding below the diaphragm
          • Penetrating injury outside the chest: survival about 16% with signs of life, 3% without (EAST 2015)
        19. ERT
        20. Path rejoins step 16Shared downstream outcome
        21. REBOA
        22. Path rejoins step 09Shared downstream outcome
        23. Head, neck or limb
        24. 21Action

          Head, neck or limb injury: continue resuscitation; consider ERT or REBOA

          Control external bleeding; continue resuscitation and adjuncts (WTA 2024). REBOA only by trained staff, if no thoracic aortic injury is suspected.

          • External bleeding: direct pressure, tourniquet
          • Penetrating neck or limb, no signs of life, CPR >5 min: survival very unlikely (WTA 2012)
        25. Continue resuscitation
        26. Path rejoins step 09Shared downstream outcome
        27. If ERT chosen
        28. Path rejoins step 16Shared downstream outcome

Guideline Source

Western Trauma Association Critical Decisions: Adult Emergency Resuscitative Thoracotomy (Tesoriero R et al., J Trauma Acute Care Surg 2024;97:961-968)

DOI: 10.1097/TA.0000000000004462View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • ERT needs a surgeon or a trained emergency or critical care doctor in hospital; many emergency departments do not have one available.
  • Time limits come from observational data; arrest and CPR times are often imprecise, so senior judgement is needed.
  • Adults only. Children: use paediatric ERT guidance.
  • Blunt injury with no signs of life: WTA 2024 allows ERT in selected patients; EAST 2015 advises against it.
  • REBOA needs trained staff and equipment that few hospitals have.
  • Resource-intensive procedure with low overall survival.

Contraindicated Populations

pediatric

Applicable Regions

AUUSEUGlobal

AU: ANZCOR 11.10.1: ERT is a hospital procedure by a surgeon or a trained emergency or critical care doctor. Prehospital thoracotomy is rarely, if ever, appropriate in Australian and NZ civilian practice. Hospitals should have local guidelines.

UK: Often performed by emergency physicians with training

US: Performed by trauma surgeons or trained emergency physicians

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Emergency Resuscitative Thoracotomy (ERT)?

The Emergency Resuscitative Thoracotomy (ERT) is a emergency clinical algorithm for Trauma Surgery. It provides a structured decision tree to guide clinical decision-making, based on Western Trauma Association Critical Decisions: Adult Emergency Resuscitative Thoracotomy (Tesoriero R et al., J Trauma Acute Care Surg 2024;97:961-968).

What guideline is the Emergency Resuscitative Thoracotomy (ERT) based on?

This algorithm is based on Western Trauma Association Critical Decisions: Adult Emergency Resuscitative Thoracotomy (Tesoriero R et al., J Trauma Acute Care Surg 2024;97:961-968) (DOI: 10.1097/TA.0000000000004462).

What are the limitations of the Emergency Resuscitative Thoracotomy (ERT)?

Known limitations include: ERT needs a surgeon or a trained emergency or critical care doctor in hospital; many emergency departments do not have one available.; Time limits come from observational data; arrest and CPR times are often imprecise, so senior judgement is needed.; Adults only. Children: use paediatric ERT guidance.; Blunt injury with no signs of life: WTA 2024 allows ERT in selected patients; EAST 2015 advises against it.; REBOA needs trained staff and equipment that few hospitals have.; Resource-intensive procedure with low overall survival.. Individual patient factors may require deviation from these recommendations.

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