Penetrating injury to the chest, and especially the heart, has a high mortality rate. The best way to reduce mortality is rapid pre-hospital transport to a trauma center where life-saving measures can be carried out immediately. Frequently, these measures include resuscitative thoracotomy. The Western Trauma Society has a well-known guideline to help with decision-making in performing this procedure.

The trauma group at Sinai Chicago recently published a paper slicing and dicing the possible predictors of survival after cardiac injury. As I read this paper, I was curious about how this information would change our practice, especially with the decision to open the chest.

The authors performed a retrospective cohort study of patients who had suffered penetrating cardiac trauma over nine years. Here are the factoids:

• Over 18,000 patient encounters were analyzed (average 2,000 per year), and only 57 penetrating cardiac injuries were identified (3%)
• Overall survival was 25% (!)
• Gunshot victims were 3.7x more likely to die
• Mortality odds ratios for specific injury patterns were as follows:
  • Multiple cardiac chambers injured 11x
  • Thoracic vascular injury 12x
  • Concurrent abdominal injury 4.4x
• These findings were noted to decrease the likelihood (odds ratio) of death:
  • Isolated cardiac injury 0.2x
  • Spontaneous respirations 0.06x
  • Signs of life on arrival 0.01x
• Every patient (35) who underwent resuscitative thoracotomy died

The authors suggested that recognizing these factors could help clinicians in decision-making processes during early triage and resuscitation.

Bottom line: When I first read the paper, it seemed that this was all common-sense information and didn’t add much to our body of knowledge. However, upon closer reading, there are some good tidbits here. The work here helps identify which patients are most likely to benefit from opening the chest. It assigns probabilities to anatomic and physiologic criteria, some of which are apparent at the time of patient arrival and are available for decision making. The fact that every patient who underwent resuscitative thoracotomy died is not alarming; it merely reflects the fact that these are patients who are the sickest of the sick. 

So how do we put the information in this paper to use? The resuscitative thoracotomy algorithm from the Western Trauma Association should be utilized first. When the patient is on the cusp of the 15-minute CPR decision point, the odds ratios in this paper might be used to tilt the scales one way or the other. Does the patient also have abdominal injuries? Are there no signs of life? Then perhaps clinician judgment may dictate that the procedure not be performed. Alternatively, if the thoracotomy is carried out in patients and any of the three high-risk anatomic indicators for death are present, they might then choose to terminate the procedure to conserve resources. 

Overall, this paper does not force any major changes in care. It informs the trauma professional and allows them to couple that information with existing algorithms and care processes, so they might either further improve the patient’s probability of survival or conserve scarce resources if survival is unlikely. 

References: 

1. Predictors of survival after penetrating cardiac trauma: injury patterns and presentation factors. Trauma Surg Acute Care
   Open 2026;11:e002237.
2. Western Trauma Association Resuscitative Thoracotomy Practice Guideline