Eastern vs. Western trauma guidelines for resuscitative thoracotomy: A comparative analysis of indications, outcomes, and philosophical approaches

BACKGROUND: Resuscitative thoracotomy (RT) for traumatic cardiac arrest (TCA) carries a high mortality, and national guidance for RT indications varies in their emphasis on signs of life (SOL) and arrest duration. The Eastern Association for the Surgery of Trauma (EAST) prioritizes SOL, while the Western Trauma Association (WTA) emphasizes prehospital arrest time. To evaluate the clinical utility of each framework, we compared survival based on adherence to EAST and WTA RT guidelines. METHODS: We conducted a retrospective review of all TCA patients who underwent RT at our ACS-verified Level 1 trauma center. Demographics, presenting features, and outcomes were abstracted from the electronic medical record. The 2012 WTA and 2015 EAST guidelines were applied to categorize each case as guideline-adherent or nonadherent. Survival outcomes at various timepoints were assessed, including neurologically intact survival (NIS; discharge without hypoxia-related neurological deficit). χ2 analysis compared survival between EAST and WTA-adherent groups. RESULTS: A total of 467 patients underwent RT; overall survival to discharge was 5.8%, and NIS was 4.7%. EAST criteria were met in 460 (98.5%), and adherence was associated with 5.9% survival and 4.8% NIS. WTA criteria were met in 371 patients (79.4%); adherence was associated with 7.0% survival and 5.9% NIS. Patients not meeting either guideline had markedly lower survival. Three survivors lacked documented SOL but met favorable time criteria; all were neurologically intact. Of 96 patients exceeding WTA-arrest time limits, 1 (1.0%) survived, but without neurological recovery. CONCLUSIONS: Despite prioritizing different clinical factors, EAST and WTA guidelines identified similar subsets of potential survivors with comparable survival outcomes. Both SOL and prehospital arrest duration are integral in predicting survival. These findings support the development of a unified, evidence-based guideline that integrates both systems to standardize practice and optimize decision-making around RT. (J Trauma Acute Care Surg. 2026;00: 000-000). LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.