A 30-year-old male was admitted to the Emergency Department for a penetrating self-inflicted left chest stab wound, extensive (80% total body surface area, TBSA) full-thickness burn injury, and carbonization. During the pre-hospital phase, the patient was intubated and the initial resuscitation was performed through crystalloids infusion. He was transferred to the nearest "hub" Trauma Center by air ambulance. At the arrival, he was hypotensive (systolic blood pressure (SBP) 80 mmHg) and tachycardic (heart rate (HR) 150 bpm). The stab wound was in the left third intercostal space, medial to the midclavicular line. The chest x-ray showed a left hypertensive massive hemopneumothorax. An E-FAST was performed, but in the subcostal window, the pericardium was not assessable, probably because of the acoustic barrier caused by skin carbonization. A left minithoracotomy was performed and a chest drainage was put in place; this was followed by the immediate return of 3000 ml of blood and air. A thromboelastography (ROTEM) and an arterial blood gas test (ABG) were performed: pH 6.8, base excess (BE) - 22, lactates 14. Tranexamic acid 1 g, two units of red blood cells, and two plasma units were transfused. The patient was transferred to the operating room (OR) to perform a thoracotomy. During the resuscitation phase, the specialist carried out a burn evaluation. A very bad prognosis was determined due to the severity of the burn injuries.
In the OR, a clamshell incision was performed and a pericardial lesion was found. A pericardiotomy showed a left ventricular full-thickness injury (grade V according to OIS-AAST system). After placing a Foley catheter in the cardiac wound, a direct prolene and metal staples suture were performed. The Foley catheter was removed without residual bleeding. Bilateral chest drainages were put in place and the thoracic wall was closed (Additional file 1). A bilateral lower limb escharotomy was performed. After the procedures, the SBP was 120 mmHg, the HR 120 bpm, and the ABG test showed the following results: pH 7.28, BE - 8.9, lactates 12, Hb 8.9 mg/dL. Thereafter, it was applied a goal directed therapy of the coagulopathy according to ROTEM results.
The patient received continuous support in intensive care unit. Due to hemodynamic instability, venoarterial extracorporeal membrane oxygenation (V-A ECMO) was initiated. This procedure allowed to preserve organs, to allow appropriate family consultation and palliative care planning. During family discussions regarding end-of-life care, the feasibility of organ donation was raised.
The further resuscitation (Table 1) allowed confirmation of medical suitability (Table 2).  
Death ascertainment took place 23 h after the arrival of the patient at the ED. The necessary procedures for DCD process for therapeutic transplantation purposes started only after the ascertainment of death with cardio-circulatory criteria and family approval.
Medical suitability for liver and kidneys donation was assessed by the Regional Reference Center for Transplants. Normothermic regional perfusion was started according to the standard procedure. After the reperfusion phase, the liver was considered unusable due to ischemic injury. One kidney was not transplanted because of technical problems. However, one kidney was successfully transplanted.