Blunt traumatic rupture of the heart and pericardium, rarely diagnosed preoperatively, carries a high mortality rate. From 1979 to 1989, more than 20,000 patients were admitted to a Level I trauma center. A retrospective review identified 59 patients requiring emergency surgery for this condition. Injuries resulted from vehicular accidents (68%), motorcycle crashes (10%), pedestrians being struck by vehicles (7%), falls (5%), crushing (7%), and being struck by a horse (2%) or crane (2%). Seventeen patients (29%) had isolated rupture of the pericardium; 37 (63%) had ruptures of one or more cardiac chambers. All patients had signs of life at the scene or during transportation, but only 29 (49%) had vital signs on admission: 15 with chamber injury, 12 with pericardial rupture, and two with combined injuries. Diagnosis was established by emergency thoracotomy in the 30 patients who arrived in cardiac arrest. In the remaining 29 patients, diagnosis was made by urgent thoracotomy (41%), by subxiphoid pericardial window (34%), during laparotomy (21%), or by chest radiography (3%). The overall mortality rate was 76% (45 patients), but only 52% for those with vital signs on admission. Rapid transportation and expeditious surgical treatment can save many patients with these injuries.