Get the spreaders in there, preferably with the ratchet on the inferior side facing the axilla. Watch your fingers, because it might be sharp! Once inside the thorax, briefly hold ventilations and move the (hopefully) collapsed L lung out of the way and find the heart. Start your pericardiotomy by cutting into the pericardium anterior and parallel to the L phrenic nerve, which should be fairly visible at this point (and stating the obvious--DON'T CUT THE PHRENIC NERVE!). You should lift up with toothed forceps and cut with your Mayo scissors.



If you'll need to perform open cardiac massage/compressions, you can "deliver" the heart from the pericardium to do so. This will also make it easier to visualize any cardiac injuries. In terms of hemorrhage control, you can temporarily use your finger, but you can also place a Foley through as well. For sutures, you can try throwing some buttressed Vicryl throws in there, but you should ultimately leave the definitive repair to the cardiothoracic surgeons (do you really want to try throwing pledgets into a moving field?).



For cardiac compressions, remember that you want to use your palms, not your fingers. Make sure that you compress perpendicular to the septum, and that you don't compress the coronaries. Also relax completely in between cycles. If there's ROSC but persistent hypotension, you can clamp the descending aorta with a DeBakey or a Kelley clamp but this can be quite challenging even with the chest open as the aorta is often collapsed in these scenarios.

