In traumatic cardiac arrest, especially due to hemorrhage or cardiac tamponade, external cardiac compression has no role in the emergency room.

Trauma patients that arrive at the emergency room in, or progress, to cardiac arrest are candidates for resuscitative thoracotomy. The indications and contraindications are controversial, with many surgeons supporting strict criteria and others supporting liberal criteria for the procedure.

The emergency room thoracotomy can be resuscitative and/or therapeutic, allowing release of cardiac tamponade, control of bleeding, direct cardiac massage, and defibrillation, aortic cross-clamping, and management of air embolism.

Endotracheal intubation, intravenous line placement, and thoracotomy can be performed simultaneously.

All staff should wear personal protective equipment.

The resuscitative thoracotomy tray should be immediately available in the emergency room. It includes only essential instruments (one scalpel, Finochietto retractor, two Duval lung forceps, two vascular clamps, one long Russian forceps, four hemostats, one bone cutter, one pair of long scissors). In addition, good lighting, suction, and an internal defibrillator should be ready before patient arrival (Figure 20.1).

An epicardial pacing device and wires should be immediately available.

Supine position with the left arm abducted at 90 degrees or above the head. Antiseptic skin preparation is performed with betadine on the anterior and left lateral chest wall.

A left anterolateral incision allows exposure to the heart and left lung, as well as access to the thoracic aorta for placement of a cross-clamp. If necessary, it can be extended as a clamshell incision into the right chest through a mirror incision and division of the sternum.

The incision is performed through the fourth and fifth intercostal space, just below the nipple in males or the infra-mammary crease in females. The incision starts at the left parasternal border and curves toward the axilla, ending at the posterior axillary line.

The intercostal muscles are divided close to the superior border of the rib, in order to avoid damage to the neurovascular bundle, and the pleural cavity is entered using scissors. Right mainstem intubation or holding ventilation during entry into the pleural cavity reduces the risk of lung injury (Figure 20.2 AC).

A Finochietto retractor is inserted and the ribs are spread. The bar of the Finochietto is placed on the axilla side to allow unobstructed access to the sternum, should a right-sided extension be required. The left lower lobe of the lung is grasped with Duval forceps and retracted laterally and cephalad to expose the heart and the thoracic aorta (Figure 20.3).

In suspected right chest or mediastinal vascular injuries, extend the left thoracotomy into a clamshell incision, by transverse division of the sternum with a bone cutter and a symmetrical right thoracotomy. During the division of the sternum, both internal mammary arteries are transected, and clamping or ligation should be performed after the restoration of cardiac activity and circulation (Figure 20.4 A,B).