Two hundred seventy patients with penetrating chest wall and thoracic injuries were treated at the Metropolitan Nashville General Hospital in a 5.5-year period ending July 1982. Most (250) were males, and the average age was 29.3 years. One hundred thirty-four injuries were the result of gunshot wounds and 18 patients had sustained shotgun wounds. Stab wounds were the cause of injury in 117 patients. Most patients were successfully treated with closed tube thoracostomy. Twenty-five patients required emergency room thoracotomy, and 27 patients were stable enough to be transported to the operating room for thoracotomy and repair of injuries. Survival in the patients who had emergency room thoracotomy was 12 per cent and 78 percent in patients who had operating room thoracotomy. All but one of the patients who died following operating room thoracotomy died within 1 hour of admission. When thoracotomy is indicated, it frequently must be performed very soon after admission. The indications for emergency thoracotomy must be known and recognized early if it is to be an effective procedure.