A 67-year-old man, who had no significant family history and past history, accidentally fell from a stepladder, which was 3 m in height, while he was pruning a plant. Owing to the resulting injuries, he was transported to our hospital. After the fall, his consciousness level was Glasgow coma scale (GCS) E3V5M6, respiratory rate (RR) was 24 breaths per min, SpO 2 was 90% (oxygen 10 L/min reservoir mask), heart rate (HR) was 96 beats per min, and blood pressure was (BP) 173/103 mmHg. On arrival, the airway was opened, RR was 28/min, SpO 2 was 90% (oxygen 5 L/min mask), BP was 148/100 mmHg, HR was 104/min, body temperature was 36.0 °C, and focused assessment with sonography for trauma (FAST) was negative. Electrocardiography revealed sinus tachycardia and heart expansion was not observed in chest X-ray images. There was no jugular venous distention, and there were no heart noises on auscultation. There was no obvious bruise on the skin surface, but he was complaining of occipital pain and left back pain. Bilateral multiple rib fracture, left lung contusion, left hemothorax, and right pneumothorax were observed on plain whole-body CT (Fig. 1), but no pericardial effusion was observed. After CT, we performed chest drainage on both sides. Drainage after indwelling was barely observed on the right side, and drainage from the left side was 300 ml. After placing the thoracic drain, he was transferred to the ICU.
The following was the clinical course after the hospitalization (Fig. 2): drainage from the left thoracic tube increased and reached almost 800 ml in 4 h from 10 h after admission. It was difficult to visualize his pericardial effusion and pleural effusion using echocardiography. As his circulatory dynamics were intact, CECT (Fig. 3) was performed to investigate the cause of the massive hemothorax. Subcutaneous emphysema was found in the chest wall. Furthermore, we found a “flattened heart sign,” suggesting pericardial effusion with extravasation and cardiac tamponade in the pericardium. After returning to the ICU, we were preparing for surgery to stop the bleeding. His HR rapidly deteriorated to 120 beats/min and BP was also 68/50 mmHg. Therefore, we determined that cardiopulmonary arrest due to cardiac tamponade was imminent. After tracheal intubation, we performed left anterior lateral thoracotomy. We identified slight bleeding that included the pulmonary parenchyma after aspiration of blood stored in the thoracic cavity. We stopped the bleeding from his chest wall by applying a thoracotomy device; hence, we thought that his massive hemothorax was caused by bilateral multiple rib fractures. We removed a hematoma that formed in the pericardial fat. Furthermore, there was no obvious open wound on the pericardium. We confirmed that there was no phrenic nerve near the hematoma and we performed a pericardiotomy on the portion where a hematoma had formed. We incised the pericardium, which resulted in a blood spurt. We then removed the hematoma in the pericardium and sutured the ruptured pericardiophrenic artery including pericardial fat, thus achieving hemostasis. The source of the damage to the heart was unclear. After pericardiotomy, his HR did not change at 120 beats/min, but his BP improved to 134/70 mmHg. We performed temporary thoracic closure with negative-pressure wound therapy using the VAC® system (Acelity L.P. Inc., San Antonio, TX) as damage control management. The operation duration was 75 min. The total amount of blood was 530 ml in the thoracic cavity. After 12 h, when we removed the VAC® system and checked the pericardium, hemostasis was achieved. Closure of the pericardium was difficult because the pericardium did not stretch. Therefore, we did not attempt to close the pericardium and we closed the chest. The postoperative course was good. A ninth thoracic spinal burst fracture was associated with the fall; hence, the patient was forced to carry out long-term bed rest. On day 41, he was discharged wearing a corset.