A 34-year-old man who had no medical history was admitted via an emergency room with blunt trauma. At admission, he was in shock status, and focused abdominal sonography for trauma showed a minimal positive sign but no abdominal distention. A trauma series showed right-sided tension hemothorax, and a chest tube was inserted (
Fig. 1.). More than 1000 mL gushed out within 30 minutes. Other injuries were fractures of the pelvic bone, tibia (open), and humerus. Therefore, emergency surgery for hemothorax was planned. Before going to surgery, I wanted to check the computed tomographic (CT) scan because the vital signs were stable for permissive hyportension. However, the CT scan showed a liver injury with unexpected diaphragmatic rupture (
Fig. 2A.,
B.). Thus the plan for thoracic surgery had to be changed to abdominal surgery. A severe liver injury with diaphragmatic rupture was found (
Fig. 3.). Because of the diaphragmatic rupture, I had missed the presence of hemoperitoneum and misinterpreted the tension hemothorax as resulting from a chest injury. I performed laparotomy and midsternotomy and then attempted surgical damage control, including tape packing around the liver and temporary abdomen closure. However, the patient died 2 days after surgery.