This is a retrospective review of patients with combined penetrating cardiac and abdominal trauma. Clinical presentation patterns are described and a management strategy is outlined. The series comprises 25 patients. On the basis of the mechanism of injury and the prognosis, the patients were divided into two groups: 'low risk' (single high epigastric stab wound) and 'high risk' (multiple stabs, single or multiple gunshot wounds). There were six patients in the low-risk group. Their intra-abdominal injuries were moderately severe. None of this group died. There were 19 patients in the high-risk group. Three underwent emergency-room thoracotomy and died. Of the remaining patients, four underwent a thoracotomy first for cardiac tamponade or massive haemothorax and 12 underwent a laparotomy first because of massive haemoperitoneum. The mortality in this group was 63 per cent. It is essential to recognize the cardiac injury in low-risk patients; the cardiorrhaphy must be performed before the laparotomy. In high-risk patients, the sequence of operations depends on the clinical presentation. Obvious cardiac tamponade or massive haemothorax mandate a thoracic approach first, while severe hypovolaemic shock with a massive haemoperitoneum justifies the performance of a laparotomy first; a transdiaphragmatic pericardiotomy is useful, in these cases, before proceeding to median sternotomy.