BACKGROUND: Blunt injury of the pericardium with strangulation of the heart is a rare clinical injury. METHODS: We conducted a review of clinical records and performed prospective collection of forensic data from a large urban medical examiner's office. RESULTS: Ten cases of blunt injury to the pericardium were identified. All were secondary to blunt trauma. Nine of the 10 cases had associated chest wall injuries and 5 of the 10 cases had cardiac strangulation. CONCLUSION: Pericardial lacerations are common findings at autopsy. Clinically, those that survive to the hospital have a confusing presentation. They are often diagnosed during emergent thoracotomy for hemodynamic instability. Hemodynamic deterioration associated with change in patient position may be a clue to cardiac strangulation.