Resuscitative thoracotomy: What you need to know

Resuscitative thoracotomy (RT) is a time-critical procedure performed in the setting of traumatic cardiac arrest, primarily to address cardiac tamponade, control intrathoracic bleeding, and reduce infradiaphragmatic blood loss. Advances in trauma care have refined the indications and improved the outcomes of RT in select patient populations. This review focuses on current techniques, indications, outcomes, and future directions. The physiologic objectives are to release pericardial tamponade, repair cardiac injuries, control intrathoracic hemorrhage, perform open cardiac massage, and provide access for aortic cross-clamping and hilar clamping for control of bronchovenous air embolism. Resuscitative thoracotomy is indicated for profound hypotension (systolic blood pressure, <60 mm Hg) or patients with a traumatic cardiac arrest who have required less than 15 minutes of cardiopulmonary resuscitation. Patients with penetrating trauma in extremis, especially with cardiac tamponade, have improved survival with RT (>15%) compared with patients with blunt trauma with RT (<2%). Future directions include refining the indications of RT with the advent of resuscitative endovascular balloon occlusion of the aorta (REBOA), defining futility, establishing the role of extracorporeal membrane oxygenation (ECMO), suspended animation, and evaluating the role of RT in patients who will become organ donors. This review aims to provide an up-to-date, evidence-based overview of RT to guide trauma providers in optimizing patient selection, procedural technique, and informed decision making regarding patient outcomes.