Cardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. Cardiac tamponade is a medical emergency. The overall risk of death depends on the speed of diagnosis, the treatment provided, and the underlying cause of the tamponade.
Incidence Frequency: The incidence of cardiac tamponade is 2 cases per 10,000 population in the United States. Approximately 2% of penetrating injuries are reported to result in cardiac tamponade.

The pericardium, which is the membrane surrounding the heart, is composed of 2 layers. The parietal pericardium is the outer fibrous layer; the visceral pericardium is the inner serous layer. The pericardial space normally contains 20-50 mL of fluid. Pericardial effusions can be serous, serosanguineous, hemorrhagic, or chylous. Reddy et al describe 3 phases of hemodynamic changes in tamponade.
Phase I: The accumulation of pericardial fluid causes increased stiffness of the ventricle, requiring a higher filling pressure. During this phase, the left and right ventricular filling pressures are higher than the intrapericardial pressure.

Symptoms vary with the underlying cause and the acuteness of the tamponade. Patients with acute tamponade may present with dyspnea, tachycardia, and tachypnea. Cold and clammy extremities from hypoperfusion are also observed in some patients.
Patients with systemic or malignant disease present with weight loss, fatigue, or anorexia.
Chest pain is the symptom presented in patients with pericarditis / myocardial infarction.
Musculoskeletal pain or fever may be present in patients with an underlying connective tissue disorder.

Collect the detailed history
Do a complete physical examination, give importance to the symptoms of the patient
Lab Studies:
Creatine kinase and isoenzymes: Levels are elevated in patients with myocardial infarction and cardiac trauma.
Renal profile and CBC count with differential: These tests are useful in the diagnosis of uremia and certain infectious diseases associated with pericarditis.

Medical Care
Cardiac tamponade is a medical emergency. Preferably, patients should be monitored in an intensive care unit.
All patients should receive the following:
Oxygen
Volume expansion with blood, plasma, dextran, or isotonic sodium chloride solution, as necessary to maintain adequate intravascular volume
Bed rest with leg elevation: This may help increase venous return.

Nursing diagnosis
Decreased cardiac output related to poor contractility of the ventricle
Pain related to increased pressure in the mediastinum
Imbalanced nutrition, less than body requirement related to anorexia, inadequate food intake
Anxiety related to unknown out come and prognosis
Risk for complication related to prolonged treatment and lowered immunity
Complications:

The synaptic knob, the space between neurons (Synaptic cleft) and the portion of the cell to which, the impulse is being transmitted constitute the synapses. According to the change in target cell; the synapse can be differentiated like neuron to neuron synapse or neuron to muscle (or gland) synapse.
As a message travels down the neuron, it reaches a synapse that it must cross to the neuron; it reaches a synapse that it must cross to “jump” to the next neuron. According to this “jumping” process the synapses can be classified into two types

A neuron not conducting a nerve impulse is said to be “resting”. Although it is resting, it remains changed and potentially ready to fire. The potential to fire is produced by an interstitial fluid within. The inside of nerve cell is electrically negative, and the interstitial fluid electrically, positive. A resulting membrane potential, is measured in electrical potential between the two compartments. The resulting membrane potentials, measured in millivolts (mV) results from this difference in electrical potential between the two compartments.
The resting membrane potential (RMP) of neurons is between -45and-75mV.

The Peripheral nervous system, or PNS, is part of the nervous system, and consists of the nerves and neurons that reside or extend outside the "CNS" central nervous system (the brain and spinal cord) to serve the limbs and organs, for example. Unlike the central nervous system, however, the PNS is not protected by bone, leaving it exposed to toxins and mechanical injuries. The peripheral nervous system is divided into the somatic nervous system and the autonomic nervous system.The somatic nervous system, also called the somatomotor or somatic efferent nervous system, supplies motor impulses to the skeletal muscles. Because these nerves permit conscious control of the skeletal muscles, it is sometimes called the voluntary nervous system. The autonomic nervous system, also called the visceral consists of nerves that go to the skin and muscles and is involved in conscious activities. The autonomic nervous system consists of nerves that connect the CNS to the visceral organs such as the heart, stomach, and intestines. It mediates unconscious activities.

Twelve pairs of cranial nerves emerge from the inferior surface of the brain. .
They are Olfactory,Optic,OcculomotorTroclerar,Abducens,Trigeminal,Facial,Vestibulocochlaer,Glossopharyngeal,Vagus,Spinal Accessory, Hypoglossal respectively.

Thirty-one pairs of spinal nerves emerge laterally from the spinal cord. Each pair of nerves corresponds to a segment of the cord and they are named accordingly. This means there are 8 cervical nerves, 12 thoracic nerves, 5 lumbar nerves, 5 sacral nerves, and 1 coccygeal nerve.
Each spinal nerve is connected to the spinal cord by a dorsal root and a ventral root. The cell bodies of the sensory neurons are in the dorsal root ganglion, but the motor neuron cell bodies are in the gray matter. The two roots join to form the spinal nerve just before the nerve leaves the vertebral column. Because all spinal nerves have both sensory and motor components, they are all mixed nerves.

Family planning as an official programme was adopted in 1952 as it was recognized that a rapidly growing population would be a more of a hindrance than help in raising the standard of living of the people.During the First and Second Five Year Plans (1951-1961), the programme was taken in amodest way with a clinical approach. The programme was recognised in the Third Plan after the publication of 1961 Census results which showed a higher growth rate than anticipated. The cliniacl approach was supplemented by extension approach under which the message, services and supplies of contraceptives were taken to the people.

The Centre provides 100% assistance to State Governments for dervice and educational purposes towards family planning
schemes. The central government controls the planning and financial management of the programmw, training, research and evaluation.
A Population Advisory Council headed by the Union Minister of Health and members of parliament and persons related to the field of population was set up in 1982. During the Second Plan period, family pkanning bureaus were established in every state at its headquaters with an Additional Director of Health Services and Family Planning to direct the programme.At the District level, since 1963, there are District Family Planning bureaus under the the charge of District Family Welfare Officers with facilities for publicity services, sterilization and the Intra Uterine Contraceptive application.

2005-2012
Recognizing the importance of health in the proces of economic and social development and improving the quality of life of our citizens, the Government of India has launched the National Rural Health Mission to carry out necessary architectural correction in the basic health care delivery system. The program was launched on April 12, 2005 by the Prime Minister Dr. Mammohan Singh.
NRHM seeks to provide effective health care to rural poulation throughout the country wiyh special focus on 18 states, which have weak public health indicators or weak infrastructure. These 18 states of federal republic of india are following the suit by creating state level nissions underperson of respectve Chief Minister of the States.Geographically, Northern and Eastern States have more challenges on Human Development front.

The mission plans to promote access to healthcare to rural households through a female health activist, ASHA. The main components are descibed below:-
COMPONENT 1: Accredition Social Health Activists (ASHA)
Every village wil have a female Accredited Socail Health Activists (ASHA) which is the refined version of community health worker, chosen by the panchayat .She will be trained on a pedagogy of public health developed and mentored through a Standing Mentoring Group at National level.She will be promoted all over the country , with special emphasis on the 18 high focus states.

Governmemt of India has set up following indicators for monitoring ASHA.
1. Process Indicators
Number of ASHAs selected by due process
Number of ASHAs trained

The Mission aims at strengthening PHC for quality preventive, promotive, curative, supervisory and outreach services, through:
Adequate and regular supply of essential quality drugs and equipment to PHCs
Provision of 24 hour service in 50% PHCs by addressing shortage of doctors, especially in high focus staes, through mainstreaming AYUSH manpower.

Each sub-center will have an United Fund for local action @Rs 10,000 per annum.This fund will be depoisted in a joint bank account of the ANM & Sarpanch and operated by the ANM, in consultation with the Village Health Committee.
Supply of essential drugs,both allopathic and AYUSH, to the sub-centers,will be ensured

A key strategy of the mission is operationalizing 3222 existing Community Health Centers(30-40 beds) as 24 hour Referral Units, including posting of anaesthetics.
Developing standards of services and cost in hospital care.
Developing, displaying and ensuring compliants to Citizen’s Charter at CHC/ PHC level.

District becomes core unit of planning, budgeting and implementation with health plan of its own. All vertical health and family welfare programme at district and state level merge into one common District Health Mission (DHM) at the district level and the “State Health Mission” (SHM) at the state level.
District Health Plan (DHP) would be an amalgation of field responses through Village Health Plans (VHP), State and National Priorities for health , water supply, sanitation and nutrition

Total Sanitation Campaign (TSC) is presently implemented in 350 district, and is proposed to cover all districts in 10th plan. Components of the TSC include
IEC activities
Rural Sanitary Marts.

National Disease Control Programms for Malaria, TB, Kala Azar, Filaria, Blindness, & Iodine Deficiency and Integrated Disease Surveillance Programme shall be integrated under the mission, for improved programme delivery.
New initiatives would be launched for the control of non communicable

Since almost 75%of health services are being currently provided by the the private sector, the district institutional mechanism for Mission mst have representation of private sector.
There is need to develop guidelines for Public-Private Partnership(PPP) in health sector and identifying areas of patnership, which are need based , thematic and geographic

A Task Group shall be created to examine new health financing mechanisms.
The District Health Mission should move towards paying hospitalsfor services by way of reimbursement .
Standardization of services and costs will be done periodically by a committee of experts in each state.

While district and tertiary hospitals are necessarily located in urban centers, they form an integral part of the referral care chain serving the needs of the rural people. Medical and para-medical education facilities need to be created in states, based on need assessment.

Merger of multiple societies and constitution of District /State Mission - June 2005
Provision of additional generic drugs at SC/PHC/CHC level - December 2005
Operational programme management units - 2005-2006
Preparation of Village Health Pans -2006

Merger of multiple societies and constitution of District /State Mission - June 2005
Provision of additional generic drugs at SC/PHC/CHC level - December 2005
Operational programme management units - 2005-2006
Preparation of Village Health Pans -2006

NATIONAL LEVEL
Infant Mortality Rate reduced to 30/1000 live births
Maternal Mortality Ratio reduced to 100/100,000

Malignant diseases are most common cause
Other causes;
HIV infection
Infection - Viral, bacterial (tuberculosis), fungal
Drugs - Hydralazine, procainamide, isoniazid, minoxidil
Postcoronary intervention (ie, coronary dissection and perforation)
Trauma
Cardiovascular surgery (postoperative pericarditis)

The accumulation of pericardial fluid
Phase Increased stiffness of the ventricle
I
Still the left & right ventricular filling pressures are higher than the intrapericardial pressure.

Neurocardiogenic (syncope vasovagal syncope & vasodepressor syncope): half of all episodes of fainting.
Caused by abnormalities in the autonomic nervous system, which controls the heart rate and circulation. vasovagal syncope is caused by both widening of the arteries and bradycardia, while vasodepressor syncope is caused by widening of the arteries alone.
Orthostatic syncope: Caused by rising rapidly from a reclined position, 30% in elderly

Dizziness or light-headedness: in 70% of patients
In the presyncopal period: Vertigo, weakness, diaphoresis, epigastric discomfort, nausea, blurred or faded vision, pallor, or paresthesias,
Time duration: an average of 2.5 minutes in vasovagal syncope, only 3 seconds in arrhythmia-related cardiac syncope.

Cardiac syncope:
The patients with cardiomyopathies, congestive hart failure and valvular insuffiency and medications that reduce afterload
Ventricular arrhythmias: ventricular tachycardia, & torsade de pointes; in older patients with known cardiac disease.
Supraventricular tachyarrhythmias: supraventricular tachycardia and atrial fibrillation
Bradyarrhythmias: sick sinus syndrome, sinus bradycardia, high-grade atrioventricular blocks, and pacemaker malfunction.

Hypovolemia: Hemorrhage, blood loss, insufficient fluid intake- as in starvation, excessive fluid losses from diarrhea or vomiting, excessive use of diuretics etc.
Decreased cardiac output: despite normal blood volume, due to severe congestive heart failure, large myocardial infarction, or bradycardia, Beta blockers can cause hypotension
Excessive vasodilation: or insufficient constriction of the resistance blood vessels; arterioles, causes hypotension. Excessive vasodilation can also result from sepsis, acidosis, or medications, such as nitrate preparations, calcium channel blockers, ACE inhibitors. Spinal anesthesia and most inhalational agents

Pre-anesthetic considerations:
Sometimes drugs are given before anesthesia is given. There are conditions that must be considered, like anxiety, so a sedative such as valium, which also causes anterograde amnesia another desired effect, can be given. Some drugs are given as prophylaxis to suppress some potential adverse responses to general anesthesia, or to minimize secretions (not so common anymore), to prevent bradycardia, or to minimize aspiration. Some of these substances, such as sodium citrate, are given to increase stomach pH so that if someone did aspirate, they wouldn’t aspirate such acidic material. Drugs are sometimes given for postoperative nausea. An antiemetic can be given pre-op or during the surgery to minimize problems. Some examples are: