<p>Prehospital Resuscitative Thoracotomy (RT) can be life-saving in traumatic cardiac arrest (TCA), particularly in patients with cardiac tamponade. Yet selecting who may benefit is challenging, as survival depends on two often uncertain factors: the underlying aetiology and the duration of arrest. Drawing on extensive prehospital RT experience, we propose a pragmatic framework based on two simple clinical surrogates. Injury location provides a useful surrogate for the likely cause of arrest, helping direct the initial resuscitation strategy, while presenting ECG rhythm offers a rapid marker of physiological viability when timelines are unclear. Combining these surrogates offers a practical decision aid: likely tamponade should prompt immediate RT when an organised rhythm is present, or when arrest duration is short even in asystole, while cases where tamponade is unlikely should prioritise transfusion and haemorrhage control, with RT reserved for those in whom tamponade is subsequently confirmed. This perspective highlights how simple bedside information, supported by governance, can guide timely, pathology-specific care and maximise the benefit of this life-saving intervention.</p> Graphical abstract <p></p>