Resuscitative Thoracotomy (Clamshell)

INDICATIONPenetrating torso injury with signs of life in the last ~15 min, or a witnessed blunt arrest under ~10 min with a surgeon. Tamponade is the pathology you are looking for — it hides with no external signs and a normal ECG.

1. Decide
   Gate it against the box above, out loud, before you touch a scalpel. The decision is the procedure.
2. Organize
   Say it. Name a surgeon to call, one airway, one transfusionist. Blood in the room before the chest is open.
3. X · A · B · C
   External bleeding first. iGel or ETT. BILATERAL finger thoracostomies. Large-bore access, blood not crystalloid.
4. Incision
   Splash prep only. LEFT 5th ICS, sternum → the table, through muscle into pleura along its whole length.
5. Rib spreader — open wide
   Finochietto in, crank handle DOWN toward the axilla — handle up blocks the clamshell. Sweep the lung aside.
6. Open the pericardium
   Tent with forceps. Long VERTICAL cut anterior to the phrenic. Clot out, deliver the heart, look at every surface.
7. Close the heart
   Finger first. Then Foley 16 Fr (5–10 mL, clamp the port) · staples · pledgeted 3-0. Under a coronary, never through.
8. Cross over if the right bleeds
   Blood on the right is the reason — a hard view on the left is not. Mirror it, split the sternum, clamp BOTH mammaries.
9. Aorta · hilum
   Compress the descending aorta against the spine. Bleeding lung → divide the pulmonary ligament, twist the hilum 180°.
10. Perfusing?
    Contraction AND output — pulse or BP. Not PEA, not a pupil. Yes → blood, TXA, calcium, OR or transfer; mammary bleeding will start. No → stop, note the time, debrief.