Trauma Patient in Extremis/Arrest
Patient in cardiac arrest or peri-arrest from trauma
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Trauma SurgeryEmergency
Emergency Resuscitative Thoracotomy (ERT)
Emergency Resuscitative Thoracotomy (ERT): Trauma Patient in Extremis/Arrest → Signs of Life (SOL)? → Mechanism of Injury? → Penetrating Injury Location...
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Decision 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
03Decision Mechanism of Injury?
Penetrating vs Blunt
04Decision Penetrating Injury Location
Cardiac vs Non-cardiac thoracic
05Decision Penetrating Cardiac
Time since SOL lost?
- Highest survival rates
- Survival: 8-35%
- ERT INDICATED if SOL lost <15 minutes
06Warning ERT INDICATED
Proceed with thoracotomy
- Left anterolateral thoracotomy
- 5th ICS, from sternum to posterior axillary line
- Can extend to clamshell if needed
07Action 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
08Action 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
09Decision ROSC Achieved?
Return of spontaneous circulation
10Outcome Transport to OR
ROSC achieved - definitive repair
11Outcome Terminate Resuscitation
No ROSC despite appropriate interventions
12Action 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
- Path rejoins step 09Shared downstream outcome
13Action 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
14Decision Penetrating Non-Cardiac Thorax
Time since SOL lost?
- Survival: 10-15%
- ERT INDICATED if SOL lost <15 minutes
- Path rejoins step 06Shared downstream outcome
- Path rejoins step 13Shared downstream outcome
15Decision Blunt Injury
Cardiac vs Non-cardiac
16Decision Blunt Cardiac
Time since SOL lost?
- Lower survival: 1-2%
- Consider if SOL lost <10 minutes
- May have survivable injury (tamponade)
- Path rejoins step 06Shared downstream outcome
- Path rejoins step 13Shared downstream outcome
17Warning Blunt Non-Cardiac
ERT generally NOT indicated
- Survival <1%
- ERT NOT recommended
- Exception: witnessed arrest with organized rhythm
- Path rejoins step 13Shared downstream outcome
- Path rejoins step 13Shared downstream outcome
Guideline Source
WTA Critical Decisions: Adult Emergency Resuscitative Thoracotomy 2024
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Requires surgical capability and trained personnel
- Resource-intensive procedure with low overall survival
- Time estimates for SOL are imprecise in field
- Patient selection is critical for meaningful survival
Applicable Regions
USEUGlobal
UK: Often performed by emergency physicians with training
US: Performed by trauma surgeons or trained emergency physicians
Version 1Next review: 2027-01-01
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Related Resources
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 WTA Critical Decisions: Adult Emergency Resuscitative Thoracotomy 2024.
What guideline is the Emergency Resuscitative Thoracotomy (ERT) based on?
This algorithm is based on WTA Critical Decisions: Adult Emergency Resuscitative Thoracotomy 2024 (DOI: 10.1097/TA.0000000000004507).
What are the limitations of the Emergency Resuscitative Thoracotomy (ERT)?
Known limitations include: Requires surgical capability and trained personnel; Resource-intensive procedure with low overall survival; Time estimates for SOL are imprecise in field; Patient selection is critical for meaningful survival. Individual patient factors may require deviation from these recommendations.
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