Resuscitative thoracotomy in traumatic cardiac arrest

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.