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Resuscitative thoracotomy in traumatic cardiac arrest

ÖGARI, ÖGOuT and other Austrian societie… · 2026 · Austria

Source and licence

Authors
Martin W Dünser, Daniel Grassmann, Thomas Hamp et al.
Title
Resuscitative thoracotomy in traumatic cardiac arrest
Journal
Wiener Klinische Wochenschrift, 2026
DOI
10.1007/s00508-026-02771-3
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC13290978

Licence statement of the original publication

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This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Results

  • A relevant caseload of patients with penetrating injuries within a geographic region accessible by EMS within 15 minRecommendation strength: Best practice statement; Quality of evidence: n. a.; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 91.7; Degree of agreement: Strong
  • A major trauma center with 24/7 thoracic or cardiac surgical capabilitiesRecommendation strength: Best practice statement; Quality of evidence: n. a.; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 91.7; Degree of agreement: Strong
  • A structured, physician-led prehospital EMSRecommendation strength: Best practice statement; Quality of evidence: n. a.; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 91.7; Degree of agreement: Strong
  • Availability of sufficient human, material, and financial resources to implement, maintain, and provide quality assurance for the practice of RTRecommendation strength: Best practice statement; Quality of evidence: n. a.; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 91.7; Degree of agreement: Strong

1.1. What are the indications to perform RT?

  • We suggest performing RT on patients with TCA following penetrating trauma to the cardiac box if signs of life are present or if the duration of cardiac arrest is < 15 minRecommendation strength: Weak; Quality of evidence: Moderate; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 95.7; Degree of agreement: Strong
  • We suggest performing RT on patients with TCA following blunt trauma and ultrasound-confirmed cardiac tamponade if signs of life or an organized ECG rhythm are present, or if the duration of cardiac arrest is < 10 minRecommendation strength: Weak; Quality of evidence: Moderate; Number of voting rounds to achieve consensus: 3; Overall agreement (%): 81.8; Degree of agreement: Moderate

1.2. Does age or functional status influence the indication to perform RT?

  • We suggest applying the same indications for RT in children as in adultsRecommendation strength: Weak; Quality of evidence: Low; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 82.6; Degree of agreement: Moderate
  • We suggest against establishing a strict upper age limit for RT; however, we suggest that RT should not be performed in patients with multimorbidity or known life-limiting underlying conditionsRecommendation strength: Weak; Quality of evidence: Very low; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 95.7; Degree of agreement: Strong

1.3. Is point-of-care ultrasound required before performing RT?

  • We suggest against the use of point-of-care ultrasound prior to performing RT in patients with TCA following penetrating trauma to the cardiac box who present with signs of life or a duration of cardiac arrest < 15 minRecommendation strength: Weak; Quality of evidence: Low; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 87.0; Degree of agreement: Moderate
  • We suggest the use of point-of-care ultrasound to identify cardiac tamponade and indicate RT on patients with TCA following blunt trauma who present with signs of life, an organized ECG rhythm, or a duration of cardiac arrest < 10 minRecommendation strength: Weak; Quality of evidence: Low; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 95.7; Degree of agreement: Strong

1.4. Should RT also be performed in pregnant women?

  • We suggest that RT should be performed in pregnant women with TCA, provided that the indications for the procedure are metRecommendation strength: Weak; Quality of evidence: Very low; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 91.3; Degree of agreement: Strong

1.5. Which factors need to be considered when indicating RT in the case of multiple casualties?

  • We suggest against categorically withholding RT in the event of multiple casualties; however, we recommend a critical evaluation in eligible patients, ensuring that sufficient human and material resources are available in both the prehospital and hospital settings to support the procedure and subsequent careRecommendation strength: Best practice statement; Quality of evidence: n. a.; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 87.0; Degree of agreement: Moderate

2.1. Which human resources are required to perform RT?

  • We suggest a minimum of 4–6 healthcare providers to perform RT. This team should include at least one emergency physician trained in the procedure and at least one provider proficient in advanced airway managementRecommendation strength: Weak; Quality of evidence: Very low; Number of voting rounds to achieve consensus: 2; Overall agreement (%): 90.9; Degree of agreement: Strong

2.2. Who should perform RT in the absence of a thoracic or cardiac surgeon?

  • We recommend that RT should only be performed by specialized physicians who are experienced in emergency medicine and specifically trained in this procedureRecommendation strength: Best practice statement; Quality of evidence: n. a.; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 95.7; Degree of agreement: Strong

2.3. Which technique should be used to perform RT?

  • We suggest using the clamshell technique as the preferred approach for performing RTRecommendation strength: Weak; Quality of evidence: Moderate; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 87.0; Degree of agreement: Moderate

2.4. Is pericardiocentesis an alternative to RT in patients with traumatic cardiac tamponade?

  • We suggest that pericardiocentesis should be reserved for patients with traumatic cardiac tamponade only when RT cannot be performed. This suggestion only applies if the required equipment and clinical expertise to perform this procedure are presentRecommendation strength: Weak; Quality of evidence: Low; Number of voting rounds to achieve consensus: 2; Overall agreement (%): 86.4; Degree of agreement: Moderate

2.5. Which requirements must the material for performing RT meet?

  • We suggest that the surgical instrumentation for RT should be standardized, streamlined, robust and user-friendly. Ideally, all necessary components should be prepacked in a compact, purpose-built thoracotomy kitRecommendation strength: Weak; Quality of evidence: Very low; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 91.3; Degree of agreement: Strong

3.1. Which specific safety measures should be taken into account when performing RT on scene?

  • As penetrating injuries are often caused by violent crimes, we suggest that RT should only be performed once scene safety has been ascertainedRecommendation strength: Best practice statement; Quality of evidence: n. a.; Number of voting rounds to achieve consensus: 2; Overall agreement (%): 100; Degree of agreement: Unanimous
  • We suggest ensuring patient privacy by using visual shielding (e.g., privacy screens) and controlling scene access during the procedureRecommendation strength: Best practice statement; Quality of evidence: n. a.; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 87.0; Degree of agreement: Moderate

3.2. Are blood products required to perform RT in the prehospital setting?

  • We suggest that blood products should be available in prehospital systems performing RT; however, their immediate availability is not a prerequisite to perform RT in the prehospital settingRecommendation strength: Weak; Quality of evidence: Very low; Number of voting rounds to achieve consensus: 2; Overall agreement (%): 86.4; Degree of agreement: Moderate

3.3. Which requirements should the receiving hospital meet to provide care for patients after RT in the prehospital setting?

  • We recommend that hospitals receiving patients following prehospital RT must be major trauma centers with 24/7 thoracic or cardiac surgical capabilitiesRecommendation strength: Best practice statement; Quality of evidence: n. a.; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 95.7; Degree of agreement: Strong
  • We suggest that both the receiving hospital and the EMS performing prehospital RT adhere to coordinated treatment and communication protocolsRecommendation strength: Best practice statement; Quality of evidence: n. a.; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 95.7; Degree of agreement: Strong

3.4. How should the emergency control centre be involved in the operational process of RT in the prehospital setting?

  • We suggest that the emergency control center serves as a critical link in the operational process of prehospital RT. Its role includes identifying eligible patients, rapidly dispatching and coordinating specialized resources and facilitating early communication with the receiving hospitalRecommendation strength: Best practice statement; Quality of evidence: n. a.; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 91.3; Degree of agreement: Strong

3.5. Should other emergency services be informed or trained about the RT process?

  • We suggest that other emergency organizations, particularly the police, should be briefed on the operational requirements of prehospital RT and encouraged to participate in joint simulations to optimize scene management and interagency coordinationRecommendation strength: Best practice statement; Quality of evidence: n. a.; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 82.6; Degree of agreement: Moderate

4.1. Which education and training are required to perform RT?

  • We suggest that physicians undergo a structured educational course including both cadaveric and multidisciplinary simulation training prior to performing RTRecommendation strength: Weak; Quality of evidence: Low; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 95.7; Degree of agreement: Strong
  • We suggest that physicians trained in RT participate in periodic refresher training to maintain procedural skills and team coordinationRecommendation strength: Weak; Quality of evidence: Low; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 100; Degree of agreement: Unanimous

4.2. Should nonphysician healthcare professionals involved in the process of RT also undergo education and training?

  • We suggest that nonphysician healthcare professionals involved in the RT process should also undergo structured education and training. This training should focus on procedural assistance, equipment familiarity and coordinated team dynamics during RTRecommendation strength: Best practice statement; Quality of evidence: n. a.; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 100; Degree of agreement: Unanimous

5.1. Which quality control measures should be taken when implementing RT?

  • We suggest that all systems performing RT implement comprehensive quality control and clinical governance measures. These should include mandatory structured case debriefings, regular clinical audits, and established feedback loops to ensure the ongoing refinement of protocols and training programsRecommendation strength: Weak; Quality of evidence: Very low; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 100; Degree of agreement: Unanimous

5.2. Which support options should be offered to healthcare professionals who performed or witnessed RT?

  • We suggest that systems performing RT provide easily accessible, low-threshold support mechanisms (e.g., peer support programs, professional psychological counselling) for all healthcare professionals who performed or witnessed RTRecommendation strength: Best practice statement; Quality of evidence: n. a.; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 100; Degree of agreement: Unanimous

6.1. Which ethical considerations should be taken into account when deciding on the indications for and performing RT?

  • We recommend that ethical decision-making must guide the indication of RT. This process must incorporate an objective assessment of survival probability, strict adherence to eligibility criteria, and a profound respect for patient dignity. Furthermore, it requires a balanced approach to resource allocation, transparent communication with families, and sensitivity to the emotional impact on both relatives and the healthcare teamRecommendation strength: Strong; Quality of evidence: Low; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 95.7; Degree of agreement: Strong

6.2. Which legal considerations should be taken into account when performing RT?

  • We recommend that physicians performing RT adhere to the established legal framework and professional statutes governing life-saving emergency procedures in their respective jurisdictionRecommendation strength: Best practice statement; Quality of evidence: n. a.; Number of voting rounds to achieve consensus: 1; Overall agreement (%): 95.7; Degree of agreement: Strong

Which requirements must healthcare systems meet to systematically implement RT?

  • We recommend that systematic implementation of RT should only be considered in healthcare systems that fulfil all of the following criteria: • A relevant caseload of patients with penetrating injuries within a geographic region accessible by EMS within 15 min. • A major trauma center with 24/7 thoracic or cardiac surgical capabilities. • A structured, physician-led prehospital EMS. • Availability of sufficient human, material and financial resources to implement, maintain and provide quality assurance for the practice of RT.

Abstract

Background: Resuscitative thoracotomy (RT) is recommended for selected patients with traumatic cardiac arrest, particularly after penetrating trauma; however, most evidence is derived from high-volume centers, creating uncertainty about its implementation in settings with a low prevalence of penetrating injuries. This study aimed to develop evidence-informed, consensus-based recommendations for the systematic implementation of RT in such contexts.

Methods: A modified Delphi process was conducted with 24 specialists representing 10 Austrian medical societies and two emergency medical services. A systematic literature review was carried out to enable the development of 22 open-ended questions. Responses from the first round were synthesized into 28 statements.

Results: Consensus was achieved on all 28 statements after 4 rounds, with participation rates of 100% in rounds 1 and 2, and 91.7% in rounds 3 and 4. The panel issued 1 strong recommendation, 15 weak recommendations and 12 best-practice statements. Agreement was unanimous in 17.9%, strong in 50.0%, and moderate in 32.1% of the statements. Evidence certainty was rated as moderate (18.8%), low (43.8%) or very low (37.5%). Key recommendations emphasized strict indication criteria, system level prerequisites such as major trauma centers and physician-led emergency services, preference for the clamshell technique and the need for structured multidisciplinary training and governance.

Conclusion: This consensus provides guidance on implementing RT in settings with a low prevalence of penetrating trauma. Careful patient selection, system preparedness and structured training are essential to optimize outcomes. These recommendations can support clinicians and policymakers in their decision if and how RT should be implemented into trauma systems with limited exposure to penetrating injuries.

Supplementary Information: The online version of this article (10.1007/s00508-026-02771-3) contains supplementary material, which is available to authorized users.

Contents of the original publication

The section headings of the original.

  • Background
  • Methods
  • Objective
  • Steering committee and expert panel selection
  • Definition of resuscitative thoracotomy
  • Systematic review of the literature
  • Development of open-ended questions to be answered by the expert panel
  • Design and conduct of the Delphi study
  • Results
  • System requirements for implementing RT
  • Which requirements must healthcare systems meet to systematically implement RT?
  • Recommendations for healthcare systems fulfilling these requirements and aiming to systematically implement RT into the practice
  • 1. Indications for RT
  • 2. Practical implementation of RT
  • 3. Special considerations when performing RT in the prehospital setting
  • 4. Education and training
  • 5. Quality management
  • 6. Ethical and legal considerations
  • Conclusion

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