Abstract Thoracic trauma causes diaphragmatic dysfunction and severe dynamic pain. Thoracic epidural continuous infusion of local anesthetic and opioid is the treatment of choice for providing effective pain relief and improved pulmonary function in patients with multiple rib fractures or flail chest. This technique leads to a reduction in pulmonary complications and hospital stay and, for elderly patients, decreased morbidity and mortality. Compared with parenteral opioids or blocks, thoracic epidurals provide superior analgesia. When used postoperatively after trauma thoracotomy or laparotomy, thoracic epidurals provide better analgesia and cardiopulmonary function and a faster return of bowel function. Because of the angulated spinous processes of the thoracic vertebrae, the paramedian approach for insertion seems to be advantageous. Patients should be adequately resuscitated before epidural placement, with particular attention to correction of hypovolemia or coagulopathy. Copyright © 2002 by W.B. Saunders Company