Annotation for Point D
After performing the thoracotomy and pericardotomy, the patient’s intrinsic cardiac activity is evaluated; patients in asystole without cardiac tamponade are declared dead. Patients with a cardiac wound, tamponade, and associated asystole are aggressively treated. First, the cardiac wound is repaired using a 3-0 nonabsorbable running suture (see F in Fig. 1). Following sufﬁcient if not complete hemostatic repair, bimanual internal massage of the heart is initiated; this should be performed with a hinged clapping motion of the hands, with the wrists apposed, sequentially closing from palms to ﬁngers. The ventricular compression proceeds from the cardiac apex to the base of the heart. Intracardiac injection of epinephrine may be administered into the left ventricle, using a specialized syringe, which resembles a spinal needle. Typically, the heart is lifted up slightly to expose the posterior left ventricle, and care is taken to avoid the circumﬂex coronary during injection. The heart is vigorously massaged to enhance coronary perfusion. After allowing time for vasopressors to circulate, the heart is deﬁbrillated (30 J) using internal paddles. Following several minutes of such treatment, as well as generalized resuscitation, salvageability is reassessed; we deﬁne this as the patient’s ability to generate a systolic blood pressure of greater than 70 mm Hg with an aortic cross-clamp if necessary.