Emergency Resuscitative Thoracotomy (ERT) is a potentially lifesaving intervention for patients who develop or have impending post-injury cardiovascular collapse or full arrest from a potentially reversible cause. While Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can be considered as an alternative in the absence of thoracic bleeding, there are still several indications for which ERT is a preferred or equivalent option.

The purposes of this procedure are:

- Control of intrathoracic hemorrhage
- Release of cardiac tamponade
- Internal cardiac massage
- Aortic occlusion to control infra-diaphragmatic hemorrhage and maximize cerebral and coronary perfusion.

Consider the following before performing ERT:

1. ERT should only be performed only at a forward military treatment facility with surgical and resuscitation capability (typically Role 2 or higher) and by individuals familiar with and trained in this procedure.
2. Absolute indications for ERT in the combat/operational environment include:

- Penetrating truncal/extremity trauma with recent loss of vitals (less than 15 minutes) or impending cardiac arrest.
- Blunt truncal/extremity trauma with pre-hospital vital signs and either witnessed arrest after arrival or refractory shock with impending cardiac arrest.

1. Additional relative indications for ERT in the combat/operational environment include:

- Penetrating or blunt truncal/extremity trauma with pre-hospital arrest but with signs of life on arrival (narrow complex EKG rhythm and/or organized cardiac contractile activity on ultrasound)
- Potentially salvageable blunt or penetrating cranial injury with vital signs and then arrest after arrival or impending arrest (uncommon)

1. ERT should NOT be performed for blunt trauma with arrest before arrival and with no signs of life (absent organized narrow complex EKG rhythm and/or organized contractile activity on cardiac ultrasound.)
2. ERT should NOT be performed during multiple or mass casualty (MASCAL) events or when performance will expend critical resources (such as blood products/surgeons/ORs) needed more salvageable patients.
3. The critical steps of an ERT include identification and release of tamponade, control of major thoracic hemorrhage, initiation of open cardiac massage, and cross-clamping the descending aorta.
4. The performance of a simultaneous right anterolateral thoracotomy or extension to a “clamshell” thoracotomy is indicated for evidence of right thoracic or mediastinal injury not reached from the left side.
5. Critical adjuncts to a successful ERT include adequate IV or IO access, endotracheal intubation, initiation of damage control resuscitation, and placement of an oro/naso-gastric tube.
6. For the patient with impending arrest, if immediate or direct transfer to the OR is available then this should be strongly considered versus performing an ERT in the resuscitation area.
7. All necessary equipment/supplies for ERT should be packaged together and stored in an easily accessible location in the resuscitation area, and should be regularly inspected and replaced/replenished as needed.
8. Trauma team training and simulation exercises should be performed at regular intervals and should include review of the necessary equipment, individual tasks, and sequence of events for an ERT
9. All personnel must wear full personal protective equipment and strict attention must be paid to control of needles/sharps to avoid iatrogenic injuries or infectious exposures (needle sticks, cuts, eye splash, etc.).

*These are general guidelines are not intended to replace expert clinical judgment and decisions based on evaluation of an individual patient, local capabilities, and operational considerations.