Open cardiac massage is indicated if absent or inadequate cardiac activity is noted after a thoracotomy for penetrating trauma, a thoracotomy to decompress pericardial tamponade (spontaneous, postsurgical, or from an aortic dissection), or a cardiac arrest after recent chest surgery.7,9,11 Other possible indications include abnormal chest wall anatomy that prevents closed chest CPR, hypothermic cardiac arrest, refractory ventricular fibrillation, massive air embolism, and if standard CPR is not effective.