A Cracking Way to Start the Year

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Picture of Zaf Qasim
Zaf Qasim
Dr Zaf Qasim is an attending physician in Emergency Medicine and Critical Care based at the University of Pennsylvania in the United States. He has particular interests in trauma, prehospital care and advanced resuscitation including endovascular techniques. You can find him on Twitter as @ResusOne

The Pre-brief

You are working a solo shift in the Emergency Department of a level 3 trauma center when a young man staggers into triage holding his chest. The nurse rushes him into the resuscitation room, and you run in to see what the commotion is about. The man clearly has a stab wound just left of his sternum and looks ashen. As you begin your primary survey, he becomes unresponsive. An ultrasound probe over the chest reveals a large pericardial effusion and cardiac motion present.

The charge nurse is already on the phone with the surgeon, who is 15 minutes away – you know her to be a veteran of the recent wars with a lot of experience. You decide you will proceed with a resuscitative thoracotomy (RT) but wonder about the best approach.

First Things First…Should I Cut?

Much has been published about the indications for RT (a better term than ED thoracotomy since the purpose is to resuscitate, not confine it to a single part of the hospital). Let’s quickly review the recommendations from relevant trauma and resuscitation societies:

Western Trauma Association (WTA)
Eastern Association for the Surgery of Trauma (EAST)
European Resuscitation Council Traumatic Arrest Algorithm

Let’s Go! But How?

By all three algorithms, a RT is indicated in this patient – you can argue that a single stab wound to the chest is the most likely to survive a witnessed arrest if you intervene quickly. Additionally and importantly, you have a surgeon on the way who can take the patient to the operating room. Remember that survival for these patients is dependent on the system being able to support you doing your intervention.

But how should you proceed? In the US, traditionally, a left anterolateral approach has been utilized by trauma surgeons and has been taught to trainees. In European training and practice models, a bilateral anterior thoracotomy approach, more commonly termed a clamshell approach, is often undertaken. As a non-surgeon, is one better over the other? Does it take longer to do?


What Am I Trying to Achieve?

Ask yourself – what needs to happen to ensure my patient lives? The answer is I need to open the chest and find out what’s damaged, then (at least temporarily) fix it. We will presume other measures like airway management and blood resuscitation are ongoing.

The reality is as a non-surgeon (and even many surgeons outside of trauma centers), you’re unlikely to have done this procedure often. You want to give your patient the best chance, and for that, you must be able to see what the problem is and have the space to address it. The anterolateral approach, while a reasonable approach, can sometimes be like looking into a dark hole. The clamshell indeed allows much more exposure – to the mediastinum AND both sides of the chest.

Three recent papers have addressed this:

  1. DuBose et al. retrospectively compared outcomes of 1218 RTs at 46 trauma centers over a six-year period. They found the clamshell RT was more likely to facilitate thoracic life-saving procedures and did not increase either systemic or thoracic complications in survivors when compared to the anterolateral approach.
  2. Newberry et al. performed a prospective trial of ED physicians performing either an anterolateral or clamshell RT on cadavers. They found that clamshell RT was more likely to be successful and resulted in fewer procedural iatrogenic injuries than the anterolateral approach.
  3. Simms et al. reviewed six different RT incision types on cadavers to assess which was the easiest to perform and allowed the best access for control of intrathoracic injury, concluding that a clamshell approach proved to be the superior choice.


But Surely a Clamshell Will Take Twice As Long?

Not necessarily. Let’s look at a couple of papers:

  1. The Newberry paper demonstrated a clinically insignificant difference in both cardiac exposure and aortic cross-clamping times with the two techniques.
  2. Flaris et al., in a prospective cadaver study, also showed very similar times with either technique to control a simulated cardiac injury.

The Debrief

  • When faced with an injury requiring a time-critical intervention, as in our case, go for the technique that will provide the most bang for the buck.
  • The evolving evidence is clear – a clamshell approach to RT can be made in about the same time as the traditional anterolateral approach, and importantly allows better access to thoracic structures that may be injured. So if you find yourself in this situation (and have the system support) – go for the clamshell.

We will go over the steps of how to do a clamshell thoracotomy in the near future.

Happy new year – I hope it’s a better one!


  1. Burlew CC et al. Western Trauma Association critical decisions in trauma: Resuscitative thoracotomy. J Trauma Acute Care Surg 2012;73(6):1359-1363 PMID: 23188227
  2. DuBose JJ et al. Does clamshell thoracotomy better facilitate thoracic life-saving procedures without increased complication compared with an anterolateral approach to resuscitative thoracotomy? Results from the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery Registry. J Am Coll Surg 2020;231(6):713-719 PMID: 32947036
  3. Flaris AN et al. Clamshell incision versus left anterolateral thoracotomy. Which one is faster when performing resuscitative thoracotomy? The tortoise and the hare revisited. World J Surg 2015;39(5):1306-1311 PMID: 25561192
  4. Newberry R et al. Prospective randomized trial of standard left anterolateral thoracotomy versus modified bilateral clamshell thoracotomy performed by emergency physicians. Ann Emerg Med 2020 (epub ahead of print). PMID: 32807537
  5. Seamon MJ et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2015;79(1):159-173 PMID: 26091330
  6. Simms ER et al. Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomic study. World J Surg 2013;37(6):1277-1285 PMID: 23435679
  7. Truhlar A et al. European Resuscitation Council guidelines for resuscitation 2015: Section 4: Cardiac arrest in special circumstances. Resuscitation 2015;95:148-201 PMID: 26477412


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