To identify evolving strategies for resuscitation and definitive management of penetrating cardiac injuries, a retrospective review of 23 such trauma victims who presented with at least one sign of life was performed. Twenty-two of 23 patients survived. Patients with hemodynamically stable (eight of 23) (pulse less than or equal to 120 and systolic blood pressure greater than or equal to 100) and unstable presentations (15 of 23) (pulse greater than 120 or systolic blood pressure less than 100) were compared to determine whether or not their hemodynamic status predicted their severity of illness based on injury severity score, anatomic complexity, early fluid requirements and length of hospitalization. No statistically important differences could be identified, suggesting that appearance at presentation does not predict severity of injury and that aggressive resuscitation and early specific diagnosis, therefore, are important to high survival rates. Rapid volume infusion and prompt drug assisted endotracheal intubation expedited the resuscitation of unstable patients and avoided the need for thoracotomy in the emergency department in 13 of 15 instances.