Penetrating Torso Injury Research Articles

Tranexamic Acid and Pulmonary Complications: A Secondary Analysis of an EAST Multicenter Trial.

Anti-inflammatory effects of tranexamic acid (TXA) in reducing trauma endotheliopathy may protect from acute lung injury. Clinical data showing this benefit in trauma patients is lacking. We hypothesized that TXA administration mitigates pulmonary complications in penetrating trauma patients. This is a post-hoc analysis of a multicenter, prospective, observational study of adults (18+ years) with penetrating torso and/or proximal extremity injury presenting at 25 urban trauma centers. Tranexamic acid administration in the prehospital setting or within three hours of admission was examined. Participants were propensity matched to compare similarly injured patients. The primary outcome was development of pulmonary complication (ARDS and/or pneumonia). A total of 2382 patients were included, and 206 (8.6%) received TXA. Of the 206, 93 (45%) received TXA prehospital and 113 (55%) received it within three hours of hospital admission. Age, sex, and incidence of massive transfusion did not differ. The TXA group was more severely injured, more frequently presented in shock (SBP < 90 mmHg), developed more pulmonary complications, and had lower survival (P < 0.01 for all). After propensity matching, 410 patients remained (205 in each cohort) with no difference in age, sex, or rate of shock. On logistic regression, increased emergency department heart rate was associated with pulmonary complications. Tranexamic acid was not associated with different rate of pulmonary complications or survival on logistic regression. Survival was not different between the groups on logistic regression or propensity score-matched analysis. Tranexamic acid administration is not protective against pulmonary complications in penetrating trauma patients.

Change in outcomes for trauma patients over time: Two decades of a state trauma system

BackgroundTrauma center mortality rates are benchmarked to expected rates of death based on patient and injury characteristics. The expected mortality rate is recalculated from pooled outcomes across a trauma system each year, obscuring system-level change across years. We hypothesized that risk-adjusted mortality would decrease over time within a state-wide trauma system. MethodsWe identified adult trauma patients presenting to Level I and II Pennsylvania trauma centers, 1999–2018, using the Pennsylvania Trauma Outcomes Study. Multivariable logistic regression generated risk-adjusted models for mortality in all patients, and in key subgroups: penetrating torso injury, blunt multisystem trauma, and patients presenting in shock. ResultsOf 162,646 included patients, 123,518 (76.1%) were white and 108,936 (67.0%) were male. The median age was 49 (interquartile range [IQR] 29–70), median injury severity score was 16 (IQR 10–24), and 87.5% of injuries were blunt. Overall, 9.9% of patients died, and compared to 1999, no year had significantly higher adjusted odds of mortality. Overall mortality was significantly lower in 2007–2009 and 2011–2018. Of patients with blunt, multisystem injuries, 17.7% died, and adjusted mortality improved over time. Mortality rates were 24.9% for penetrating torso injury, and 56.9% for shock, with no significant change. Mortality improved for patients with ISS < 25, but not for the most severely injured. ConclusionsOver 20 years, Pennsylvania trauma centers demonstrated improved risk-adjusted mortality rates overall, but improvement remains lacking in high-risk groups despite numerous innovations and practice changes in this time period. Identifying change over time can help guide focus to these critical gaps.

The contribution of helicopter emergency medical services in the pre-hospital care of penetrating torso injuries in a semi-rural setting

BackgroundAlthough the merit of pre-hospital critical care teams such as Helicopter Emergency Medical Services (HEMS) has been universally recognized for patients with penetrating torso injuries who present with unstable physiology, the potential merit in patients initially presenting with stable physiology is largely undetermined. The ability to predict the required pre-hospital interventions patients may have important implications for HEMS tasking, especially when transport times to definitive care are prolonged.MethodsWe performed a retrospective cohort study of patients who sustained a penetrating torso injury and were attended by the Air Ambulance Kent Surrey Sussex (AAKSS) over a 6-year period. Primary outcome was defined as the percentage of patients with penetrating torso injuries requiring HEMS-specific interventions anytime between HEMS arrival and arrival at hospital. Secondary outcomes were the association of individual patient- and injury characteristics with the requirement for HEMS interventions.ResultsDuring the study period 363 patients met inclusion criteria. 90% of patients were male with a median age of 30 years. 99% of penetrating trauma incident occurred more than 10-min drive from a Major Trauma Centre (MTC). Presenting GCS was > 13 in 83% of patients. Significant hemodynamic- or ventilatory compromise was present in more than 25% of the patients. Traumatic cardiac arrest was present in 34 patients (9.4%), profound hypotension with SBP < 80 mmHg in 30 (8.3%) and oxygen saturations < 92% in 30 (8.3%). A total of 121 HEMS-specific interventions were performed. Although HEMS-specific interventions were associated with presenting physiology (TCA OR 1.75 [1.41–2.16], SBP < 80 mmHg (OR 1.40 [1.18–1.67] and SpO2 < 92% (OR 1.39 [1.17–1.65], a minority of the patients presented initially with stable physiology but deteriorated on route to hospital and required HEMS interventions (n = 9, 3.3%).ConclusionHEMS teams provide potentially important contribution to the pre-hospital treatment of patients with penetrating torso injuries in rural and semi-rural areas, especially when they present with unstable physiology. A certain degree of over-triage is inevitable in these patients, as it is hard to predict which patients will deteriorate on route to hospital and will need HEMS interventions. The results of this study showing a potentially predictable geographical dispersion of penetrating trauma could inform multi-agency knife crime prevention strategy.

Penetrating Torso Injury Cause by a Steel Bar

Penetrating Torso Injury Cause by a Steel Bar

Diagnostic accuracy of triple-contrast multi-detector computed tomography for detection of penetrating gastrointestinal injury: a prospective study.

Neither the performance of CT in diagnosing penetrating gastrointestinal injury nor its ability to discriminate patients requiring either observation or surgery has been determined. This was a prospective, single-institutional observational study of patients with penetrating injury to the torso who underwent CT. Based on CT signs, reviewers determined the presence of a gastrointestinal injury and the need for surgery or observation. The primary outcome measures were operative findings and clinical follow-up. CT results were compared with the primary outcome measures. Of one hundred and seventy-one patients (72 gunshot wounds, 99 stab wounds; age range, 18-57years; median age, 28years) with penetrating torso trauma who underwent CT, 45% were followed by an operation and 55% by clinical follow up. Thirty-five patients had a gastrointestinal injury at surgery. The sensitivity, specificity, and accuracy of CT for diagnosing a gastrointestinal injury for all patients were each 91%, and for predicting the need for surgery, they were 94%, 93%, 93%, respectively. Among the 3% of patients who failed observation, 1% had a gastrointestinal injury. CT is a useful technique to diagnose gastrointestinal injury following penetrating torso injury. CT can help discriminate patients requiring observation or surgery. • The most sensitive sign is wound tract extending up to gastrointestinal wall. • The most accurate sign is gastrointestinal wall thickening. • Triple-contrast CT is a useful technique to diagnose gastrointestinal injury. • Triple-contrast CT helps to discriminate patients requiring observation and surgery.

Trauma team activation criteria in managing trauma patients at an emergency room in Thailand.

Trauma team activation (TTA) criteria were first implemented in the Emergency Department (ED) of Songklanagarind Hospital in 2009 to treat severe trauma patients. To determine the efficacy of the TTA criteria on the acute trauma care process in the ED and the 28-day mortality rate. A 1-year prospective cohort study was conducted at the ED. Trauma patients who were 18years old and over who met the TTA criteria were enrolled. Demographic data, physiologic parameters, ED length of stay (EDLOS), and the injury severity score (ISS) were recorded. Multiple logistic regression was used to determine the factors affecting 28-day mortality. Institutional review board approval was obtained from the Prince of Songkla University. A total of 80 patients (74 male and 6 female) were eligible with a mean age of 34.3years old. Shock, penetrating torso injury, and pulse rate >120 beats per minute were the three most common criteria for trauma team consultation. At the ED, 9 patients (11.3%) were non-survivors, 30 patients (37.5%) needed immediate operation, and 41 patients (51.2%) were admitted. All of the arrest patients died (p<0.0001). The median time of EDLOS was 85min: 68min in the non-survivor group and 120min in the survivor group (p=0.028). The median ISS was 21.0 (1-75): 25.0 in the non-survivor group and 17.0 in the survivor group. When compared with pilot data prior to TTA implementation, the median time of EDLOS improved from 184 to 85min and the 28-day mortality rate decreased from 66.7 to 46.3%. The high ISS was a predictor of death. The trauma team activation criteria improved acute trauma care in the ED which was demonstrated by the decreased EDLOS and mortality rate. A high ISS is the sole parameter predicting mortality.

Penetrating Wounds to the Torso: Evaluation with Triple-Contrast Multidetector CT

Penetrating injuries account for a large percentage of visits to emergency departments and trauma centers worldwide. Emergency laparotomy is the accepted standard of care in patients with a penetrating torso injury who are not hemodynamically stable and have a clinical indication for exploratory laparotomy, such as evisceration or gastrointestinal bleeding. Continuous advances in technology have made computed tomography (CT) an indispensable tool in the evaluation of many patients who are hemodynamically stable, have no clinical indication for exploratory laparotomy, and are candidates for conservative treatment. Multidetector CT may depict the trajectory of a penetrating injury and help determine what type of intervention is necessary on the basis of findings such as active arterial extravasation and major vascular, hollow viscus, or diaphragmatic injuries. Because multidetector CT plays an increasing role in the evaluation of patients with penetrating wounds to the torso, the radiologists who interpret these studies should be familiar with the CT findings that mandate intervention.

Is pre-hospital thoracotomy necessary in the military environment?

Introduction Exsanguination from penetrating torso injury is a major source of mortality on the battlefield. Advanced Life Support guidelines suggest ‘on-scene’ thoracotomy for patients in cardiac arrest following penetrating chest trauma. This requires significant resourcing and training. Experience from published series (31 pre-hospital thoracotomies with 3 survivors) suggests that when this manoeuvre is applied to a well selected group it is a significant and life-saving procedure. Can this be applied to military injuries? Methods Over a 12 month period on Operation Herrick all patients who sustained significant thoracic trauma were retrospectively reviewed. Parameters were recorded to allow detailed analysis of injury pattern and operative management. Our main objective was to determine if an early (pre-hospital) thoracotomy would have influenced the outcome. Results Over the period, 81 patients required operative intervention following thoracic trauma: 8 patients underwent emergency thoracotomy (performed as part of the resuscitation) and 14 underwent urgent thoracotomy (performed after physiology partly restored). There were 9 fatalities—7 undergoing emergency thoracotomy and 2 post-operatively from multi-organ failure. Of the 7 intra-operative deaths 4/7 patients had thoracic injury and 6/7 had additional abdominal injuries. The median predicted survival of fatalities was 2.0% using Trauma Injury Severity Scoring. Discussion Emergency thoracotomy should be performed in cardiac arrest following penetrating trauma as soon as possible. Highest survival rates in both in-hospital and pre-hospital thoracotomy are found in isolated cardiac stab wounds (19.4%). Poorest survival is found in multiply, ballistic injured patients (0.7%). The latter best reflects the injury pattern of military patients who have cardiac arrest following penetrating torso injury. Conclusion As our injury pattern suggests, any pre-hospital thoracotomy on military patients is likely to require complex intervention in very challenging environments. Our evidence does not support the notion that earlier thoracotomy could improve survival.

Selective Nonoperative Management of Penetrating Torso Injury From Combat Fragmentation Wounds

Historically, military surgical doctrine has mandated exploratory laparotomy for all penetrating fragmentation wounds. We hypothesized that stable patients with abdominal fragmentation injuries whose computerized tomography (CT) scans for intraperitoneal or retroperitoneal penetration disclosed nothing abnormal, can be safely observed without therapeutic laparotomy. We retrospectively studied all hemodynamically stable patients with penetrating fragmentation wounds to the back, flank, lower chest, abdomen, and pelvis evaluated by abdominal physical examination (PE), CT, or ultrasound treated during a 6-month period at one combat support hospital. Sensitivity, specificity, and positive and negative predictive values were calculated comparing each positive test to laparotomy and each negative test to successful nonoperative management. One hundred forty-five patients met study criteria. Based on CT scans, 85 (59%) patients were managed nonoperatively; 60 (41%) underwent laparotomy. Forty-five of 60 (75%) of laparotomies were therapeutic. CT scan for intraperitoneal or retroperitoneal penetration that disclosed nothing abnormal was 99% predictive of successful nonoperative management. In detecting intra-abdominal injury requiring laparotomy, sensitivity for each method was 30.2% (PE), 11.7% (ultrasound), and 97.8% (CT) (p < 0.05). Specificity was 94.8% (PE), 100% (ultrasound), and 84.8% (CT). The areas under the receiver operating characteristic (ROC) curves were 0.565 (PE), 0.543 (ultrasound), and 0.929 (CT) (p < 0.0001). All patients with a positive ultrasound (n = 4) underwent therapeutic laparotomy. PE alone was unreliable in stable patients with abdominal fragmentation injuries. The clinical value of ultrasound results was limited, likely because the majority of these stable patients did not have injuries associated with the large accumulation of peritoneal fluid. CT scan safely and effectively analyzed nonoperative management of penetrating abdominal fragmentation injuries and should be the diagnostic study of choice in all stable patients without peritonitis with abdominal, flank, back, or pelvic combat fragmentation wounds.

Suicide bombing attacks: Can external signs predict internal injuries?: Almogy G, Mintz Y, Zamir G, et al. Ann Surg 2006;243:541–6

This retrospective chart review of victims of suicide bombers in Jerusalem describes the frequency and pattern of injuries as predictors of blast lung injury (BLI) and intra-abdominal injury. The database was prospectively collected and included demographic data, Injury Severity Scores (ISSs), as well as other information related to the event. Over a 2-year period, 17 bombing attacks resulted in 430 patient visits to the Emergency Department. Of these, 157 (37%) patients were admitted and included in this review. External injuries were mapped onto nine different body areas with a multiply injured person defined as having four or more areas affected. Blast environments were recorded into three different settings: buses, semi-confined places, and open spaces. Of the 154 patients, 28 (18%) suffered BLI and the median ISS for these patients was 21. Injuries occurring in buses or semi-confined space were associated with more severe BLI. Independent predictors of BLI were injury to four or more areas (odds ratio [OR] = 4.1; 95% confidence interval [CI] 1.5–11.0) and penetrating head injury (OR = 3.5; 95% CI 1.0–12.1). Predictors of intra-abdominal injury were injury to four or more areas (OR = 4.9; 95% CI 1.8–13.1) and penetrating torso injury (OR = 22.3; 95% CI 2.6–192.6). The authors concluded that the environment of the blast influences BLI and that intra-abdominal injuries are more commonly from direct penetrating injury as opposed to the concussive wave of the blast. Predictably, ISS and multiple injuries also help predict those patients most urgently needing care in the chaotic aftermath of suicide bombings.

Intraoperative Blood Salvage in Penetrating Abdominal Trauma: a Randomised, Controlled Trial

Blood is a scarce and costly resource. Transfusion is often required after major trauma but blood may not be readily available, and concerns remain over the potential adverse consequences of allogeneic blood transfusion. Intraoperative blood salvage (IBS) is used extensively after blunt abdominal trauma, but when blood is contaminated by enteric contents its use has been considered contraindicated. This was a randomised, controlled trial conducted with Ethical Review Board approval in an inner city trauma unit. Patients with penetrating torso injury requiring a laparotomy and who had exhibited hypotension either pre-hospital or on arrival and in whom there was considered to be significant blood loss were randomly assigned to 2 groups. The control group was given allogeneic blood transfusion at the discretion of the attending medical staff. The cell save (CS) group underwent IBS with transfusion of both allogeneic and autologous blood. All patients received prophylactic antibiotics. The primary outcome was exposure to allogeneic blood up to the first 24 hours postinjury. Twenty-three patients were entered into the control group and 21 into the CS group. The groups were equivalent in demographic details, injury patterns and injury severity. The mean volume of salvaged blood re-infused in the CS group was 1,493 ml (range 0-2,690 ml). The mean number of units of allogeneic blood transfused in the first 24 hours in the control group was 11.17 compared to 6.47 in the CS group (P=0.008). Enteric injury had been sustained in 17/23 (75%) of the control group and 18/21 (85%) of the CS group (P=NS). Survival in the control group was 8/23 (35%) compared to 7/21 (33.3%) in the CS arm (P=NS). Patients with documented postoperative sepsis were significantly more likely to die compared to those without sepsis (P=0.04); however, those patients in the CS arm were no more likely to develop sepsis compared to those who received allogeneic blood alone. In this randomised, controlled trial for patients with penetrating abdominal injuries, IBS led to a significant reduction in allogeneic blood usage with no discernable effect on rates of postoperative infection or mortality.

Suicide Bombing Attacks

To report the distribution and types of injuries in victims of suicide bombing attacks and to identify external signs that would guide triage and initial management. There is a need for information on the degree to which external injuries indicate internal injuries requiring emergency triage. The medical charts and the trauma registry database of all patients who were admitted to the Hadassah Hospital in Jerusalem from August 2001 to August 2004 following a suicide bombing attack were reviewed and analyzed for injury characteristics, number of body areas injured, presence of blast lung injury (BLI), and need for therapeutic laparotomy. Logistic analysis was performed to identify predictors of BLI and intra-abdominal injury. The study population consisted of 154 patients who were injured as a result of 17 attacks. Twenty-eight patients suffered from BLI (18.2%) and 13 patients (8.4%) underwent therapeutic laparotomy. Patients with penetrating head injury and those with > or =4 body areas injured were significantly more likely to suffer from BLI (odds ratio, 3.47 and 4.12, respectively, P < 0.05). Patients with penetrating torso injury and those with > or =4 body areas injured were significantly more likely to suffer from intra-abdominal injury (odds ratio, 22.27 and 4.89, respectively, P < 0.05). Easily recognizable external signs of trauma can be used to predict the occurrence of BLI and intra-abdominal injury. The importance of these signs needs to be incorporated into triage protocols and used to direct victims to the appropriate level of care both from the scene and in the hospital.

A prospective evaluation of ultrasonography for the diagnosis of penetrating torso injury.

Ultrasound (US) is commonly used for the diagnosis of hemoperitoneum after blunt abdominal trauma, but the value of US as an aid for identification of operative lesions after penetrating trauma is not well documented. The purpose of this investigation was to determine the accuracy of US for the evaluation of penetrating torso trauma and to assess the impact of this information on patient management. We conducted a prospective cohort observational study of consecutive penetrating torso patients at a Level I trauma center. During the 6-month trial period, 177 victims of penetrating torso trauma were assessed by our trauma teams. Ninety-two patients had stab wounds, 84 patients had gunshot wounds, and 1 patient had a puncture wound. All 28 patients with positive US examination had an exploratory laparotomy or thoracotomy (one patient had more than one procedure), resulting in 26 therapeutic operations. There were 149 negative US examinations, but in this group, 36 patients underwent laparotomy or thoracotomy, and 28 had therapeutic operations. The overall accuracy of the US examination was therefore 85%, the sensitivity was 48%, and the specificity was 98%. There were only three patients who had their initial management altered by a positive US examination. The US examination lacks sensitivity to be used alone in determining operative intervention after gunshot or stab wounds. Rarely does US information contribute to the management of patients with penetrating abdominal injuries.

Fluid resuscitation in pre-hospital trauma care: a consensus view

Fluid administration for trauma in the pre-hospital environment is a challenging and controversial area. The available evidence does not clearly support any single approach. Nevertheless, some provisional conclusions may be drawn. We believe that the following guidelines represent a sound expert consensus. It is intended that they will be modifi ed as future research brings clarity to the area. When treating trauma victims in the pre-hospital arena cannulation should take place en route where possible. Only two attempts at cannulation should be made. Transfer should not be delayed by attempts to obtain intravenous access. Entrapped patients require cannulation at the scene. Normal saline may be titrated in boluses of 250 ml against the presence or absence of a radial pulse (caveats; penetrating torso injury, head injury, infants).

The routine use of sonography in penetrating torso injury is beneficial.

Torso sonography (focused assessment with sonography for trauma [FAST]) has been added to our protocols for the evaluation of penetrating torso injury. The purpose of this study was to evaluate our recent experience and determine whether the use of FAST is beneficial. From January 1999 to January 2000, patients with penetrating torso injury and no clinical indication for surgery were evaluated by sonography with a selective use of other investigations. FAST consisted of sonographic views of the peritoneum and/or pericardium to determine the presence or absence of fluid. During the study period, there were 238 victims of penetrating injury assessed by our trauma service, and sonography was performed in 72 (30%) patients as per our protocols. There were 31 stab, 37 gunshot/shotgun and, and 4 puncture wounds. Thirty-eight patients had peritoneal views, 6 patients had pericardial views, and 28 patients had both pericardial and peritoneal views obtained. Thirteen of 66 patients had free fluid in the peritoneal cavity and 12 of the 13 patients had a therapeutic laparotomy. No peritoneal fluid was seen in 53 of 66 patients, of whom 6 had abdominal injuries, 5 requiring surgery for diaphragm or bowel injuries. The sensitivity of FAST alone for abdominal injury was 67%, specificity was 98%, positive predictive value was 92%, and negative predictive value was 89%. Pericardial fluid was seen in 3 of 34 patients; one had a heart wound and two had negative pericardial windows. All 31 patients without pericardial fluid recovered without surgery. The routine use of sonography in penetrating torso injury is beneficial. The detection of pericardial or peritoneal fluid is clinically useful. However, a negative FAST examination does not exclude abdominal injury, such as a diaphragm or hollow viscus wound, and further investigation or close follow-up is required.

Fluid Resuscitation in Pre-Hospital Trauma Care: a consensus view

Fluid administration for trauma in the pre-hospital environment is a challenging and controversial area. There is not yet any equivocal answer which can be supported by clear unanswerable evidence. Nevertheless,...

Emergency Room Thoracotomy: A Single Surgeon's Thirteen-Year Experience

Our objectives were to elucidate the postoperative complications in patients who have had emergency room thoracotomy (ERT), to define anatomic and physiologic parameters that are compatible with survival and to document the evolution of management of these patients. A single surgeon's experience over a 13-year period was reviewed. All patients where he was the primary or supervising surgeon for the ERT were included. Data were analyzed for mechanism (penetrating/blunt), hospital where performed, survival to intensive care unit, survival to discharge, and postoperative complications. Among survivors, data were analyzed for the anatomic injuries and the patients' physiologic condition in the field and on arrival. There were a total of 102 patients; penetrating injury 94 (92 percent); blunt, 8 (8 percent). Ten patients (10 percent) reached the intensive care unit alive. Three of the ten (30 percent) died at 2 hours, 12 hours, and 7 days postoperatively. Seven patients survived to hospital discharge. All seven had penetrating chest injuries and were not in cardiac arrest when first examined by paramedics. Four of the seven survivors (57 percent) had major complications. Survival for the early period was 1.6 percent (1/62) and for the later period 15 percent (6/40); P < 0.05. During the study period, changes in patient management included 1) for penetrating torso injury, withholding ERT when survival was extremely unlikely; 2) increased use of blood- and fluid-warming measures; 3) elimination of aortic cross-clamping, instead judiciously using manual compression; 4) making the main purpose of ERT the relief of cardiac tamponade; and 5) immediately controlling any cardiac injury with a simple running suture on a large needle. We conclude the following: 1) The postoperative course after ERT carried significant mortality and morbidity. 2) Compatibility with survival required both the absence of cardiac arrest when initially evaluated in the field and the presence of penetrating chest injury. 3) Significant changes occurred in patient management during this 13-year period. Survival was higher in the latter part of this period.

Reappraisal of Emergency Room Thoracotomy in a Changing Environment

The efficacy of resuscitative emergency room thoracotomy (ERT), particularly in blunt injury, has been questioned. Wide application of the procedure may not be cost effective. The risk of exposure and lethal infection to medical personnel during ERT is considerable. For the past decade, the policy at this institution has been to perform ERT on all moribund patients sustaining penetrating torso injury and all patients sustaining blunt injury with any evidence of cardiac electrical activity. To evaluate whether such a liberal policy is currently justified, the charts of all patients undergoing ERT over a 4-year period were reviewed. One hundred twelve patients underwent ERT; 24 (21%) sustained penetrating injury, 88 (79%) blunt injury. The overall survival rate was 1.8%. Penetrating injury had a 4.2% survival and blunt injury 1.1%. No patients with CPR initiated at the scene and required throughout transport survived. In those patients with both blood pressure and spontaneous respirations present in the field, survival rate was 11.8%. Survival rate in patients manifesting sinus rhythm or ventricular fibrillation upon arrival at the ER was 6.4%. No survivors were noted among patients coming to the hospital with an idioventricular rhythm or asystole. The total hospital charges for patients undergoing ERT exceeded reimbursement by $59,565. Screening for HIV and hepatitis could be documented in only two patients; both were negative. Liberal performance of ERT has dismal results, incurs monetary loss, and affords a greater potential for exposure to lethal infection. Emergency room thoracotomy is justified only when vital signs or a resuscitatible cardiac rhythm are present in the field or ER and deteriorate shortly before thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)