Resuscitative Thoracotomy

Reviewed and revised 19 April 2024


Resuscitative thoracotomy is a thoracotomy performed prehospital, in the emergency department or elsewhere that is an integral part of the initial resuscitation of a patient; an alternate term is emergency thoracotomy

  • survival 4-33%
  • determinants of survival include mechanism of injury, the location of injury and the presence or absence of vital signs
  • best outcomes in:

-> penetrating chest
-> those exsanguinating from chest tube
-> isolated chest trauma
-> cardiac injuries
-> abdominal trauma/extra-thoracic haemorrhage that benefits from aortic clamping/manual occlusion
-> time since loss of vitals – generally cited as <10 minutes since penetrating, <5 minutes since blunt

Timing of loss of vitals can be difficult as patients may be obtunded, have extremely low blood pressures but still technically have an output or pre-hospital care may be frantic. Therefore, some grace is given to these times in suitable cases (i.e. young, limited comorbidities.)

  • ETT
  • Bilateral chest decompression with finger thoracostomy being the preferred method
  • Shock or arrest with a suspected correctable intrathoracic lesion
  • Specific diagnosis (cardiac tamponade, penetrating cardiac lesion or aortic injury)
  • Evidence of ongoing thoracic haemorrhage
  • Extra-thoracic haemorrhage in a patient in whom aortic cross-clamping/manual occlusion may be beneficial


  • penetrating injury + arrest + previous signs of life
  • blunt injury + arrest + previous signs of life


  • Penetrating injury + no signs of life and CPR > 10min
  • Blunt injury + no signs of life > 5 minutes
  • Multiple severe blunt trauma
  • Non-survivable head injury


  1. Intubate (reverses hypoxia) and alleviates potential airway obstruction
  2. Bilateral finger thoracostomies, with drains not being required immediately (can place these once ROSC achieved, thoracostomies can be re-fingered in the case of tension re-accumulating)
  3. Large bore access (14g ACF, RIC Line, MAC Sheath, Swan Sheath) and balanced transfusion through rapid infuser device
  4. Resuscitative Thoracotomy
  5. Limit crystalloid as this worsens outcome in penetrating thoracic trauma unless haemorrhage controlled
  6. Limit inotropes and pressors until circulation restored (will need once defect repaired)


  1. Don full PPE including gown, safety glasses and double-glove (for potential of sharps injury on broken ribs/scalpel)
  2. Provide most sterile field possible with chlorhexidine/iodine solution
  3. Start on the left side by extending your thoracostomy incision with a scalpel through skin, medially to the sternum and laterally to the mid-axillary line.
  4. Insert heavy duty scissors into thoracostomy incision through intercostal muscle into pleural cavity and further incise intercostals from sternum to mid-axillary line
  5. Insert ‘Finochietto’ rib-spreader or similar, ensuring the handle is positioned in the axilla (ensuring that you don’t block access to a clamshell), and spread the ribs to gain access to the left pleural cavity
  6. Sweep the left lung out of the field
  7. Use artery forceps or similar to ‘pick-up’ the pericardium and carefully incise the pericardium to create a large window to relieve tamponade and access the heart. Cephalad-Caudal incision to avoid transection/injury of the left phrenic nerve that traverses the pericardium.
  8. Deliver the heart from the pericardium and inspect for injuries
  9. Insert hand along the posterior aspect of the left pleural cavity until you find the descending aorta and provide manual occlusion to the aorta. This helps to increase afterload and thereby increases perfusion to the coronary arteries and brain.
  10. Consider extending your thoracotomy to a clamshell if there is potential pathology for you to address in the contralateral pleural cavity
  11. Extending the thoracotomy means repeating steps 4 and 5 and then using heavy scissors or a Gigli saw to bisect the sternum to complete the clamshell thoracotomy


  • Relieve cardiac tamponade
  • Control haemorrhage from trauma to heart and repair defects in heart chamber(s)
  • Perform internal cardiac massage
  • Occlude aorta to increase blood flow to heart and brain (manual occlusion or cross-clamp)
  • Control life threatening thoracic bleeding
  • Control bronchovenous air embolism

Potential interventions:

  • Relieve tamponade (Cephalad-Caudal incision through pericardium avoiding L phrenic nerve)
  • Repair cardiac wounds (non-absorbable sutures 3-0, Staples, occasionally foley catheter) being careful not to injure or occlude coronary vasculature
  • Mitigate massive lung or hilar bleeding with finger/hilar twist/direct repair (partial or intermittent occlusion may be performed to avoid right heart failure)
  • Identify aortic injuries (repair with 3.0 non-absorbable sutures or use finger)
  • Consider aortic cross clamping or manual compression at level of diaphragm (limits spinal cord ischaemia)
  • Address profuse bleeding from intercostal or internal mammillary vessels
  • Perform internal cardiac massage
  • Internal Defibrillation/Intracardiac adrenaline


Journal articles and textbooks

Social media and web resources

CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

Dr David P Cosford LITFL Author Emergency physician

MBBS (UWA), FACEM, CCPU. Emergency Physician at Sir Charles Gairdner Hospital. Interests in Simulation, Critical Care, Point of Care Ultrasound and Medical Education. I help to operate a local winery in the Swan Valley focussing on producing wine from organically grown grapes and minimal intervention techniques. Love videogames, wine, gin, Chip and sneakers.

One comment

  1. Hi Chris, I was just wondering about the indication ‘severe head injury’ you have listed here . My understanding was that a suspected severe head injury, and certainly a likely non-survivable head injury, were more contraindicative.


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