The objectives of the ERT are always the same, no matter the injuries: to stop the bleeding and restore adequate central perfusion. Immediate attention should be paid to the most lethal potential findings, such as cardiac tamponade, penetrating cardiac injury, great vessel injury, and massive pulmonary injury. In the event that the injury is on the right side of the heart or chest, the standard ERT incision may be extended to the bilateral thoracotomy or “clamshell” incision with extension across the sternum. ERT is a well-codified procedure that can be considered in several steps:

1. Left anterior-lateral thoracotomy incision
2. Opening the pericardium
3. Control of a cardiac injury
4. Temporary control of active lung bleeding
5. Cross-clamping of the descending aorta
6. Internal cardiac massage and defibrillation
7. Repair of other thoracic, abdominal or peripheral injuries

Concurrent massive transfusion protocol, as well as potential pharmacological adjuncts, is essential. Rapid successful restoration of cardiac function is the key to deciding on the relevance of continuing the procedure.

The detailed technical steps are presented in detail in Appendix B.