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Background  Blunt Traumatic Pericardial Rupture (BTPR) with resulting cardiac herniation following chest trauma is an unusual and often fatal condition. Although there has been a multitude of case reports of this condition in past literature, the recurring theme is that of a missed injury. Its occurrence in severe blunt trauma is in the order of 0.4%. It is an injury that frequently results in pre/early hospital death and diagnosis at autopsy, probably owing to a combination of diagnostic difficulties, lack of familiarity and associated polytrauma. Of the patients who survive to hospital attendance, the mortality rate is in the order of 57-64%.    Methods  We present two survivors of BTPR and cardiac herniation, one with a delayed penetrating cardiac injury secondary to rib fractures. With these two cases and literature review, we hope to provide a greater awareness of this injury    Conclusion  BTPR and cardiac herniation is a complex and often fatal injury that usually presents under the umbrella of polytrauma. Clinicians must maintain a high index of suspicion for BTPR but, even then, the diagnosis is fraught with difficulty. In blunt chest trauma, patients should be considered high risk for BTPR when presenting with:  Cardiovascular instability with no obvious cause  Prominent or displaced cardiac silhouette and asymmetrical large volume pneumopericardium  Potentially, with increasing awareness of the injury and improved use and availability of imaging modalities, the survival rates will improve and cardiac  H erniation could even be considered the 5 th   H  of reversible causes of blunt traumatic PEA arrest.

Blunt traumatic pericardial rupture and cardiac herniation with a penetrating twist: two case reports