The multiply injured patient with significant thoracic and extra-thoracic injuries poses a number of challenges. Pericardial tamponade, tension pneumothorax and massive hemothorax can and should be diagnosed clinically. In more stable patients, chest computed tomography (CT) scan is an excellent screening test. The concept of damage control resuscitation and damage control surgery have shown promise in patients with multiple, critical injuries. Beta-blockade of patients with blunt thoracic aortic injuries can be used as a temporizing damage control measure when the risks of operation or intervention are very high (traumatic brain injury, severe right or bilateral pulmonary contusion, unstable pelvic fractures). Patients with multiple penetrating wounds require the surgical team to be expeditious and flexible, and damage control is a helpful strategy in these patients.