Massive intrapericardial and intrathoracic hemorrhage secondary to unusual injuries causing cardiopulmonary arrest

A 28-year-old man sustained multiple stab wounds. During transport by emergency medical services, the patient suffered cardiac arrest and required cardiopulmonary resuscitation (CPR). On arrival, he was ‘in extremis’. Vital signs: blood pressure 58/33 mm Hg; pulse 144 bpm; respiratory rate 33 bmp; and oxygen saturation 85%. He was immediately intubated. In the right femoral and subclavian veins 8.5 French catheters were placed. Fluid resuscitation was started using Lactated Ringer's, 2 units of uncross-matched packed red blood cells (PRBCs) and 2 units of fresh frozen plasma (FFP). Physical examination revealed 6 non-bleeding stab wounds, 2–3 cm each, located 1 cm below the right midclavicular line; 1 cm lateral and below the left sternoclavicular junction; 1 cm below and 2 cm medial to the right scapula; 2 cm medial to the midborder of the left scapula; in the right abdominal flank, at the posterior axillary line, 3 cm above the right iliac crest; and a right anterior midthigh wound. The patient had decreased breath sounds in both hemithoracic cavities. Bilateral 36 French chest tubes were placed at the fifth intercostal spaces. The right-sided chest tube produced 500 mL of blood, the left produced 1 L. A focused assessment with sonography for trauma (FAST) scan revealed significant fluid in the pericardium. A chest X-ray (figure 1) revealed moderate hemothorax on …