Closed tube thoracostomy is a common and very useful procedure in therapy of acute thoracic injury. However, it is not without risk. With aggressive use of this procedure in the emergency department, the incidence of technical complications was 1 percent. Our review suggests that complications can be further diminished by the routine use of large thoracostomy tubes that are placed well up on the chest after confirmation of an open pleural space, by avoiding the use of a trocar for tube placement, and by the use of a high volume, low pressure suction system. Empyema was the most common complication associated with tube thoracostomy after trauma. It occurred in 2.4 percent of the patients. Its exact causes is not known, and the role of prophylactic antibiotics needs to be established.