Emergency thoracotomy has become a mainstay in the resuscitation of patients with major thoracic injuries. It also is occasionally useful in several other life-threatening conditions. The specific indications for emergency thoracotomy are reviewed, and expeditious thoracotomy in the emergency department, when necessary, is advocated. Due to the strategic problems associated with carrying out such a major procedure in the emergency department, the grave prognosis for many of the patients for whom thoracotomy is considered, and the great expense of the procedure, emergency physicians must be aware of the specific indications and likely outcome when considering such a procedure.