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This study was designed to determine whether out-of-hospital clinical signs could be associated with functional survival for pulseless, unconscious victims of penetrating trauma.A retrospective review of medical data and outcome for pulseless, unconscious penetrating urban trauma victims during 1993-1994. For comparison with the penetrating study group, data for blunt pulseless, unconscious trauma victims for the same period are reported. Logistic regression, odds ratios, positive predictive values, sensitivity, and specificity were used to determine the possible association of field clinical signs with survival.A total of 879 penetrating and blunt trauma victims met criteria of the study. Four of 497 victims of penetrating injury survived. Three of the four survivors were neurologically intact, with the remaining survivor impaired but functional in a supervised work setting. All survivors of penetrating trauma had monitored cardiac electrical (sinus rhythm or sinus tachycardia) activity on presentation in the field, and three were stabbing victims. Age, total field treatment time, spontaneous respiration, reactive pupils, and return of pulse in the field were not found to be associated with survival. Four victims of penetrating injury survived long enough to donate perfused asystolic-sensitive (kidney, liver, lung, and pancreas) organs. There were 382 victims of blunt injury that met study inclusion criteria with five survivors. None of the five survivors of blunt injury had good neurologic function.Functional survival was rare but did occur with penetrating trauma presenting pulseless and unconscious in the out-of-hospital setting. Although the presence of a pulseless sinus rhythm or tachycardia and stabbing as a mechanism seemed to indicate better survival rates, our study failed to identify reliable out-of-hospital criteria to separate salvageable penetrating trauma victims from those who are nonsalvageable. With this lack of reliable criteria, aggressive prehospital resuscitation efforts and rapid transport to the nearest trauma center for pulseless, unconscious victims of penetrating injury seem indicated.