A 45-year-old woman was involved in a high-speedrear-endmotorvehiclecollisionandwastransportedby ambulance to our level I trauma centre. Shearrived to the emergency department with a heartrate of 116 beats per minute, and a systolic bloodpressure of 70 mm Hg without jugular venousdistention. Her initial Glasgow Coma Scale was 11.She was intubated in the emergency department.She had bilateral breath sounds, and weak but palp-able femoral pulses. Her hypotension respondedappropriately to initial resuscitation with 4 l of crys-talloid and two units of packed red blood cells(PRBC). Initial chest X-ray demonstrated a widenedmediastinum. Subsequent radiographs revealed aquestion of a left pneumothorax for which a tubethoracostomy was performed. Initial focused assess-ment by ultrasound for trauma (FAST) examinationdemonstratednofreeintraperitonealfluid;however,afollowupultrasoundshowedasmallamountoffluidin Morison’s pouch. There was no evidence of peri-cardialeffusion.Thepatient’shaemodynamicstatusnormalized and she was transported for computedtomography (CT). Her chest CTwas remarkable for aperiaortichaematomaalongthedescendingthoracicaorta with pericardial blood (Fig. 1B and C) andmultiple rib fractures. Abdominal CT also demon-stratedasmallamountoffreefluidwithoutevidenceof solid organ injury (Fig. 1B). During CTimaging thepatient developed recurrent hypotension despiteongoing aggressive resuscitation. This findingtogether with the CT observation prompted us totake the patient to the operating room intendingtoperformapericardialwindowasthesmallamountoffreefluidobservedbyCT-abdomendidnotexplainthedegreeofhypotension.Apericardialwindowwasperformed and demonstrated the presence of grossblood. Thus, a median sternotomy was immediatelyundertaken. This revealed a 3 cm laceration ofthe intrapericardial IVC at its junction with the rightatrium. This injury was primarily repaired using4-0 non-absorbable monofilament sutures withpledgets. Because of the intrapericardial injuryidentified and the small amount of fluid in detectedbyCT-abdomen.Anexploratorylaparotomywasper-formed to exclude an intrahepactic IVC injury. Thisdemonstrated a linear tear in the liver along thefalciform ligament. This injury was managed by acombination of electrocautery and applicationof topical haemostatic agents. No other intra-abdominal injuries were noted. Postoperative aorticangiography revealed no evidence of thoracic aorticinjury. Her post-operative course was notable for