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The benefits of emergency room thoracotomy (ET) in the treatment of blunt trauma are controversial. We retrospectively reviewed 38 consecutive cases in whom blunt trauma required thoracotomy as part of the resuscitative maneuver. There were no survivors in this setting regardless of age, sex, and time from injury to arrival. A review of the literature shows questionable salvage rates in such circumstances. Victims of blunt trauma presenting without signs of life are poor emergency thoracotomy candidates, and we suggest that in such patients this procedure be abandoned. Guidelines for emergency room thoracotomy are suggested: that ET should be used in penetrating chest trauma; that it is indicated for noncardiac injuries only if there is pupil reactivity, voluntary respiratory efforts, or purposeful movement, initially or during resuscitation; following ET, if spontaneous cardiac activity cannot be maintained and systemic blood pressure cannot be maintained at least at 70 mm Hg for 30 minutes, patients should be considered unsalvageable.