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.

Mortality/Morbidity: Cardiac tamponade is a medical emergency. Early diagnosis and treatment are crucial to reduce morbidity and mortality. Untreated, it is rapidly and universally fatal.

Sex: In children, cardiac tamponade is more common in boys than in girls, 7:3. In adults, cardiac tamponade appears to be slightly more common in men than in women. 1.25:1

Age: Cardiac tamponade related to trauma or HIV is more common in young adults, whereas tamponade due to malignancy and/or renal failure occurs more frequently in elderly individuals

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Causes

For all patients, malignant diseases are the most common cause of pericardial tamponade. Tamponade can occur as a result of any type of pericarditis.

• HIV infection

• Infection - Viral, bacterial (tuberculosis), fungal

• Drugs - Hydralazine, procainamide, isoniazid, minoxidil

• Postcoronary intervention (ie, coronary dissection and perforation)

• Trauma

• Cardiovascular surgery (postoperative pericarditis)

• Postmyocardial infarction (free wall ventricular rupture, Dressler syndrome)

• Connective tissue diseases - Systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis

• Radiation therapy

• Iatrogenic - After sternal biopsy, transvenous pacemaker lead implantation, pericardiocentesis, or central line insertion

• Uremia

• Idiopathic pericarditis

• Complication of surgery at the esophagogastric junction such as antireflux surgery

• Pneumopericardium (due to mechanical ventilation or gastropericardial fistula)

Other Problems to be considered:

Large pleural effusion
Tension pneumopericardium

Rapid and labored breathing

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.

• Phase II: With further fluid accumulation, the pericardial pressure increases above the ventricular filling pressure, resulting in reduced cardiac output.

• Phase III: A further decrease in cardiac output occurs, which is due to equilibration of pericardial and left ventricular (LV) filling pressures.

The underlying pathophysiologic process for the development of tamponade is markedly diminished diastolic filling because transmural distending pressures are insufficient to overcome the increased intrapericardial pressures.

Systemic venous return is also altered during tamponade. Because the heart is compressed throughout the cardiac cycle due to the increased intrapericardial pressure, systemic venous return is impaired and right atrial collapse occurs. During inspiration, intrapericardial and right atrial pressures decrease because of negative intrathoracic pressure. This results in augmented systemic venous return to right-sided chambers and a marked increase in the right ventricular volume. Because the pulmonary vascular bed is a vast and compliant circuit, blood preferentially accumulates in the venous circulation, at the expense of LV filling. This results in a reduced cardiac output.

The amount of pericardial fluid needed to impair the diastolic filling of the heart depends on the rate of fluid accumulation and the compliance of the pericardium. Rapid accumulation of as little as 150 mL of fluid can result in a marked increase in pericardial pressure and can severely impede cardiac output, whereas 1000 mL of fluid may accumulate over a longer period without any significant effect on diastolic filling of the heart. This is due to adaptive stretching of the pericardium over time. A more compliant pericardium can allow considerable fluid accumulation over a longer period without hemodynamic insult.

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.

• A history of renal failure can lead to a consideration of uremia as a cause of pericardial effusion.

• Careful review of a patient's medications may indicate drug-related lupus leading to a pericardial effusion.

• Recent cardiovascular surgery, coronary intervention, or trauma can lead to the rapid accumulation of pericardial fluid and tamponade.

• Consider HIV-related pericardial effusion and tamponade if the patient has a history of intravenous drug abuse or opportunistic infections.

• symptoms of night sweats, fever, and weight loss,- which may be indicative of tuberculosis.

Signs of the cardiac tamponade are,

• Distended neck veins.

• The Beck triad or acute compression triad

• Physical findings refer to increased jugular venous pressure, hypotension, and diminished heart sounds.

• These findings result from a rapid accumulation of pericardial fluid. However, this classic triad is usually observed in patients with acute cardiac tamponade.

• Pulsus paradoxus or paradoxical pulse: This is an exaggeration (>12 mm Hg or 9%) of the normal inspiratory decrease in systemic blood pressure.

• Kussmaul sign

• Ewart sign

• The 'y' descent

1. Collect the detailed history

2. Do a complete physical examination, give importance to the symptoms of the patient

3. 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.

• Coagulation panel: The prothrombin time and activated partial thromboplastin time are useful for determining bleeding risk during interventions, such as pericardial drainage, the placement of pericardial windows, or both.

• Antinuclear antibody assay, erythrocyte sedimentation rate, and rheumatoid factor: Although nonspecific, results from these tests may give clues to a connective tissue disease predisposing to the development of pericardial effusion.

• HIV testing: Approximately 24% of all pericardial effusions are reported to be associated with HIV infection.

• Purified protein derivative testing: This is used to diagnose tuberculosis, which is an important and not uncommon cause of pericardial effusion and tamponade.

4. Imaging studies

• Chest radiography findings may show cardiomegaly, water bottle–shaped heart, pericardial calcifications, or evidence of chest wall trauma

• Although echocardiography provides useful information, cardiac tamponade is a clinical diagnosis The following may be observed with 2-dimensional echocardiography:

• An echo-free space posterior and anterior to the left ventricle and behind the left atrium: After cardiac surgery, a localized posterior fluid collection without significant anterior effusion may occur and may readily compromise cardiac output.

• Early diastolic collapse of the right ventricular free wall

• Late diastolic compression/collapse of the right atrium

• Swinging of the heart in its sac

• LV pseudohypertrophy

• A greater than 40% relative inspiratory augmentation of right-side flow

• A greater than 25% relative decrease in inspiratory flow across the mitral valve

• Conditions that may simulate pericardial effusion on 2-dimensional echocardiography findings include the following:

• A large left pleural effusion

• Any tumor surrounding the heart

• Mitral annular calcification

• A descending thoracic aorta

• A catheter in the right ventricle

• An enlarged left atrium

• An annular subvalvular LV aneurysm

• A bronchogenic cyst

5. Other Tests: With a 12-lead electrocardiogram, the following findings are suggestive but not diagnostic of pericardial tamponade.

Sinus tachycardia

• Low-voltage QRS complexes

• Electrical alternans (also observed during supraventricular and ventricular tachycardia): Alternation of QRS complexes, usually in a 2:1 ratio, on electrocardiogram findings is called electrical alternans. This is due to movement of the heart in the pericardial space. Electrical alternans is also observed in patients with myocardial ischemia, acute pulmonary embolism, and tachyarrhythmias.

• PR segment depression

6. Procedures:

• Swan-Ganz catheterization

7. Histologic Findings: Occasionally, a pericardial biopsy is performed when the etiology of the pericardial effusion that caused the tamponade is unclear. This is especially useful in cases of tuberculous pericardial effusions because cultures of the pericardial fluid in these cases rarely yield a positive result for mycobacteria.

Medical Care

Cardiac tamponade is a medical emergency. Preferably, patients should be monitored in an intensive care unit.

1. 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.

• Inotropic drugs (eg, dobutamine): These can be useful because they do not increase systemic vascular resistance while increasing cardiac output.

• Positive-pressure mechanical ventilation: This should be avoided because it may decrease venous return.

2. Further medical care includes the following:

• Pericardiocentesis: Removal of pericardial fluid is the definitive therapy for tamponade.

• Emergency subxiphoid percutaneous drainage: This is a life-saving bedside procedure. The subxiphoid approach is extrapleural; hence, it is the safest for blind pericardiocentesis. A 16- or 18-gauge needle is inserted at an angle of 30-45° to the skin, near the left xiphocostal angle, aiming towards the left shoulder. When performed emergently, this procedure is associated with a reported mortality rate of approximately 4% and a complication rate of 17%.

• Echocardiographically guided pericardiocentesis (often performed in the cardiac catheterization laboratory): This is usually performed from the left intercostal space. First, mark the site of entry based on the area of maximal fluid accumulation closest to the transducer. Then, measure the distance from the skin to the pericardial space. The angle of the transducer should be the trajectory of the needle during the procedure. Avoid the inferior rib margin while advancing the needle to prevent neurovascular injury. Leave a 16-gauge catheter in place for continuous drainage.

• Percutaneous balloon pericardiotomy: This can be performed using an approach similar to that for echo-guided pericardiocentesis, in which the balloon is used to create a pericardial window.

• Treatment of the underlying cause to prevent recurrence

3. Drug :

Dobutamine (Dobutrex) -- Synthetic catecholamine and a direct inotropic agent that stimulates cardiac beta-receptors with minimal increase in systemic vascular resistance.

Surgical Care: For a hemodynamically unstable patient or one with recurrent tamponade, provide the following care:

2. Surgical creation of a pericardial window: This involves the surgical opening of a communication between the pericardial space and the intrapleural space. Open thoracotomy and/or pericardiotomy may be required in some cases, and these should be performed by an experienced surgeon.

3. Pericardiodesis or sclerosing the pericardium: This is a therapeutic option for patients with recurrent pericardial effusion or tamponade. Through the intrapericardial catheter, corticosteroids, tetracycline, or antineoplastic drugs (eg, anthracyclines, bleomycin) can be instilled into the pericardial space.

4. Pericardio-peritoneal shunt: In some patients with malignant pericardial effusions, creation of a pericardio-peritoneal shunt helps prevent recurrent tamponade.

5. Pericardiectomy: Resection of the pericardium (pericardiectomy) through a median sternotomy or left thoracotomy is rarely required to prevent recurrent pericardial effusion and tamponade.

Nursing diagnosis

1. Decreased cardiac output related to poor contractility of the ventricle

2. Pain related to increased pressure in the mediastinum

3. Imbalanced nutrition, less than body requirement related to anorexia, inadequate food intake

4. Anxiety related to unknown out come and prognosis

5. Risk for complication related to prolonged treatment and lowered immunity

Complications:

• Pulmonary edema

• Shock

• Death

Prognosis:

Prognosis depends on prompt recognition and management of the condition and the underlying cause of the tamponade.

Conclusion

Cardiac tamponade is a medical emergency condition in which fluid accumulates in the pericardium. The elevated pericardial pressure puts significant pressure on the heart, causing a decrease in diastolic filling of the ventricles, and hence in stroke volume. The end result is ineffective pumping of blood, shock and often death.

Cardiac tamponade occurs when the pericardial space fills up with fluid faster than the pericardial sac can stretch. If the amount of fluid increases slowly the pericardial sac can expand to contain a liter or more of fluid prior to tamponade occurring. If the fluid occurs rapidly (as may occur after trauma or myocardial rupture) as little as 100 ml can cause tamponade.

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

1. An electrical synapse

2. A chemical synapse

In an electrical synapse, the electrical nerve impulses of two cells cross directly through a very small separation (called gap junction or nexus) from the presynaptic to the postsynaptic cells; this type of synapses is found in smooth and cardiac muscles.

In chemical synapses, the chemical substances called neuro transmitters are discharged into the space (cleft) between two neurons and proposal the message onto the next neurotic presynaptic neurons to post synaptic neuron. The neuro transmitter excites, inhibits or modifies signals to the second neuron by interacting with the receptors on its membrane .More than 100 neuro transmitters have been identified. Important one’s are

1. Acetylcholine

2. Serotonine

3. Dopamine

4. Nor-epinephrine

5. Gamma amino butyric acid

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 cell is depolarized when an influx of sodium makes the membrane potential more sensitive (i.e.; rising to zero).In most cells this is due to an electrical stimulus transmitted by an adjacent cells. Depolarization is the restoration of the membrane polarity and sodium and potassium are retuned to their usual places via the sodium – potassium pump.

After an action potential is generated no segment of the nerve fiber can conduct another action potential for a brief period of time (<1ms).>absolute refractory period. Sodium and potassium are returning to their original locations during the period and sodium cannot enter the nerve cell. During his period, called the relative refractory period, only a stimulus stronger than the ordinary one can produce an action potential. On an average a return to a resting potential takes approximately 10-30ms.Myelin sheath surrounds most of the large nerve fibers and is separated by the nodes of Ranvier. Action potentials are generated only at the nodes, and thus they skip between them rather than depolarize the entire membrane. This jumping characteristic is known as saltatory conduction. Conduction using this process is rapid. The nerve impulse conduction is also related to the diameter of the fiber, the greater the diameter, the faster the impulse.

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.

The autonomic nervous system is a visceral efferent system, which means it sends motor impulses to the visceral organs. It functions automatically and continuously, without conscious effort, to innervate smooth muscle, cardiac muscle, and glands. It is concerned with heart rate, breathing rate, blood pressure, body temperature, and other visceral activities that work together to maintain homeostasis. The autonomic nervous system has two parts, the sympathetic division and the parasympathetic division. Many visceral organs are supplied with fibers from both divisions. In this case, one stimulates and the other inhibits. This antagonistic functional relationship serves as a balance to help maintain homeostasis.

Twelve pairs of cranial nerves emerge from the inferior surface of the brain.

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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.

In1966, a full-fledged Department of Family Planning was created. During the three Annual Plans (1966-69), the family planning programme, which was descibed as the “kingpin” of the Plan, was made the time bound and target oriented with vastly increasing funds. In the Fourth Plan, the programme was given the highest priority. The approch during this Plan aws to integrate increasingly family welfare services with those for health, maternal and child care and nutrition.The family welfare workers were converted into multipurpose workersto enable them to pay special attention to surveying to family welfare motivation and services.The Seventh Plan (1985-90) envisages new targets.

The country had adopted the long-term demographic goal of reducing the net reproduction rate to 1 by 2000 AD.

The National Family Welfare Programme has four components.

1. Administration and Organization which includes recruitment of staff, getting eqipment and supplies.

2. Training-Medical, paramedical and social workers in this field .

3. Social and Health

4. Supplies and Services.

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.

The District Family Welfare staff consists of

District Family Welfare Officer	1
Medical Officers	2
Extension educator	2
Information Officer	1
Statistician	1
Administrative Officer	1
Clerk/Ancillary staff	1

Urban family welfare centres are being reorganized and have established according to the population. At present there are 1499 urban family welfare centres in the country .In the rural areas, family planning programme has been integrated along with MCH service programme of the existing health care infrastructure i.e PHC.

CENTRAL

CENTRAL MINISTER OF HEALTH AND FAMILY WELFARE

SECRETARY OF HEALTH AND FAMILY WELFARE

DEPARTMENT OF FAMILY WELARE

SPECIAL SECRETARY

SECRETARIAL TECHNICAL WING WING

JOINT SECRETARY COMISSIONER

• Additional Secretary Policy Division

• Additional Secretary Aided Program Division

• Additional Secretary Plan Budget

• Additional Secretary Organized Opeartional media

• Field MCH , Media and Communication

• Additional Secretary Mass and Transport Division

• Additional Secretary Supply and Intelligence

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.

DIRECTOR

Sri Chandra Mathur ,State Institute of Health and Family Welfare,Rajasthan

He is a public health specialist working for developing human resources for health .His current assignment involves him consistently in organizing in-service trainings for health professionals.

PREAMBLE

• Provision of a Health activist in each village –ASHA(Accredited Social Health Activist)

• Village Health plan prepared through panchayat implentation.

• Stregthening of Rural Hospital on IPHS.

• Integrating of Vertical Health and Family welfare.

GOALS

• Reduction of Infant Mortality Rate (IMR) and Maternal Mortality Rate (MMR) BY 50% from existing levels in next 7 years.

• Universal access to public health services such as women’s health, child’s health, water, sanitation and hygiene, immunization and nutrition.

• Prevention and control of communicable and non-communicable diseases,including

locally endemic diseases.

• Access to integrated comprehensive primary healthcare.

• Population stabilization, gender and demographic balance.

• Revitalize local health traditions and mainstream AYUSH.

• Promotion of healthy life styles.

GUIDING PRINCIPLES

• Promote Equity

• Enhance People orientation and community based approaches

• Ensure Public Health focus

• Recognize value of traditional knowledge base of commumication

• Decentralize and involve local bodies

STRATEGIES

I CORE STRATEGIES

• Promote acess to improved healthcare at household level through the female health activists (ASHA)

• Train and enhance capacity of Panchayati Raj Institutions (PRIs) to own, control and manage public health services.

• Health Plan for each village through Village Health Committee of the panchayat .

• Stregthening sub-center through an united fund to enable local planning and action and more Multipurpose Workers(MPWs).

• Preparation and Implementation of an inter-sectoral District Health Plan prepared by the District Health Mission, including drinking water, sanitation & hygiene and nutrition.

• Stregthening existing PHCs and CHCs, and provision of 30-50 bedded CHC per lakh population for improved curative care to a normative standard.

• Integrating vertical Health and Family Welfare programs at National, State, Block, and District levels.

• Technical Support to National, State and District Health Missions, for Public Health Management.

• Stregthening capacities for data collection, assessment and review for evidence based planning, monitoring and supervision.

• Formulation of transparent policies for deployment and carer development of Human Resources for health.

• Developing capacities for preventive healthcare at all levels for promoting healthy lifestyles, reduction in consumption of tobacco and alcohol, etc

• Promoting non-profit sector particularly in under-reserved areas.

II SUPPLEMNTARY STRATEGIES

• Regulation of Private Sector including the informal rural practitioners to ensure availability of quality srvice to citizenz at reasonable cost.

• Promotion of Public Private Partnerships for achieving public health goals.

• Mainstreaming AYUSH –revitalizing local health traditions.

• Reorienting medical education to support rural health issues including regulation of Medical care and Medial Ethics.

• Effective and viable risk pooling and social health insurance to provide health security to the poor by ensuring accessible, affordable, accountable and good quality hospital care.

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.

Selection of ASHA

• Must be a resident of the village- a women married /widow/divorced

• Age group 25-45yrs

• With formal eduaction up to 8th class, having communication skills and leadership qualities.

• Norm for selection will be one ASHA for 1000 population .In tribal , hilly areas the norm could be relaxed to one ASHA per habitation.

At present one lakh ASHA’s have been selected and trained.

Role and Responsibility of ASHA

• ASHA will take steps to craete awareness and to provide information to the community on determinants of health such as nutrition, basic sanitation and hygiene practices, healthy living condition and information about existing health services.

• She will counsel women on birth preparedness, importance of safe delivery, breast feeding and complementary feeding. Immunization, contraception and prevention of STD/RTI and care of young child

• ASHA will mobilise and facilitate them in accessing health and health related services availableat the anganwadi/sub-centre/PHC such as immunization, ante-natal checkup, post-natal checkup, supplementary nutrition and sanitation.

• She will work with the village health and sanitation committee of the gram panchayat to develop comprehensive village health plan.

• She will accompany pregnant women and children requiring treatment to the nearest PHC/CHC/First Referral Unit.

• ASHA will provide primary medical care for minor ailments such as diarrhoea, fever, and first aid for minor injuries.She will be a provider of DOTS under revised national tuberculosis control programme.

• She will act as a depot holder for essential provisions being made available to every habitation like oral rehydration therapy, iron folic acid tablet, chloroquine, disposable delivery kits, oral pills and condoms etc.Adrug kit will be provided to each ASHA.

• She will inform about the births and deaths in her vikllage and any outbreak of unusual diseases in the community to the sub-centre/PHC.

• She will promote construction of household toilets under total sanitation campaign.

Role and integration of ASHA with ANM

Anganwadi worker will guide ASHA in performing the following activities:-

• Organising Health Day once/twice a month.

• AWWs and ANMs will act as a resource for the training of of ASHA.

• IEC activity through display of posters, folk dance etc.to sensitize the beneficiaries on health related issues.

• Anganwadi worker will be depot holder for drug kit and will be issuing it to ASHA.

• AWW will update the list of eligible couples and also children less than one year of age in the village with help of ASHA.

• ASHA will support the AWW in mobilising pregnant and lactating women and infants for nutrition supplement.

Auxillary Nurse Midwife (ANM) will guide ASHA in performing activities:-

• She will hold weekly/ fortnightly meeting with ASHA and discuss the activities during the week.

• AWWs and ANMs will as a resource for the training of of ASHA.

• ANMs will inform ASHA regarding the date and time of outreach sesion.

• She will take help of ASHA in updating eligible couple register

• She will utilise ASHA in motivating pregnant women for coming to sub-centre for initial check ups.

• ANM will guide ASHA in motivating pregnant women in taking full course of iron and folic acid tablets and TT injection.

• ANM will orient ASHA on the dose schedule and side effects of oral pills.

• ANMs will educate ASHA on danger signs of pregnancy and labour so that she can timely identify and help beneficiary in getting further treatment.

• ANMs willinform ASHA on date, time and place for initial and periodic training schedule.

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

• % of ASHAs attending review meeting after one year

2. Outcome Indiactors:

• % of newborn who were weighed and families counseled

• % of children with diarrhoea who received ORS.

• % of deliveries with skilled assistance

• % of institutional deliveries

• % of JSY claims made to ASHA.

• % of of completely immunized in 12-23 months of age group

• % of unmet need for spacing contraception among BPL

• % of fever cases who received chloroquine within first week in a malaria detcted area.

3. Impact Indicators:

• IMR

• Child malnutritionrates

• Number of cases of TB /Leprosy detected as compared to previous year.

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.

• Observance of Standard treatment guidelines and protocols.

• 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

• Sanction of new sub-centers as per 2001 population norm

• Upgradation of existing sub-centers,including buildings for sub-centers fuctioning in rented premises will be considered.

• 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.

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.

• Individual household toilets.

• Woman Sanitary Complex

• School Sanitation Programme.

• 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

• disease.

• Disease Surveillance System at village level would be strengthened.

• Mobile Medical Unit will be provided at District Level for improved outreach services.

• 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

• Public sector should play the lead role in defining the framework and sustaining this partnership.

• 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.

• All existing CHCs will have wage component paid on monthly basis.

• Community Based Health Insurance Schemes (CBHI) will be encouraged as part of the Mission.

• The Central Government will provide subsides to cover a part of the premiums for the poor, and monitor the schemes.

• 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

• ASHA at village level (with drug kits) -2005-2006

• Upgrading of rural hospitals -2005-2007

• Operationalising district planning - 2005-2007

• Mobile Medical Unit at district level -2005-2008

• 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

• ASHA at village level (with drug kits) -2005-2006

• Upgrading of rural hospitals -2005-2007

• Operationalising district planning - 2005-2007

• Mobile Medical Unit at district level -2005-2008

1. NATIONAL LEVEL

   • Infant Mortality Rate reduced to 30/1000 live births

   • Maternal Mortality Ratio reduced to 100/100,000

   • Total Fertility Rate reduced to 2.1

   • Malaria mortality reduction rate -50% upto 2010, additional 10% by 2012

   • Kala azar mortality reduction rate -100% by 2010, and sustaining elimination until 2012

   • Filaria /microfilaria reduction rate -70% by 2010, 80% by 2012 and elimination by 2015

   • Dengue mortality reduction rate -50% by 2010 and sustaining at that level until 2012.

   • Japanese Encephalitis mortality reduction rate-50% by 2010 and sustaining at that level until 2012.

   • Cataract Operation –increasing to 46 lakh per year until 2012.

   • Leprosy prevalence rate-reduce from 1.8/10,000 in 2005 to less than 1/10,000 thereafter.

   • Tuberculosis DOTS service- maintain 85% cure rate through entire Mission period

   • Increase utilization of First Referral Units from less than 20% to 75%

   • Engaging 250,000 female Accredited Social Health Activists (ASHA) in 10 states.

2. COMMUNITY LEVEL

• Availability of trained community level worker at village level, with a drug kit for general ailments.

• Health Day at anganwadi level on a fixed day/month for provision of immunization, ante/post natal checkups and services related to mother and child healthcare, including nutrition.

• Availability of generic drugs for common ailments at sub-centre and hospital level.

• Good hospital care through assured availability of doctors, drugs and quality services at PHC/CHC level.

• Improved access to Universal Immunization through induction of Auto Disabled Syringes, alternate vaccine delivery and improved mobilization services under program.

• Improved facilities for institutional delivery through provision of referral, transport, escort and improved hospital care subsidized under theJanani Suraksha Yojana (JSY) for the Below Poverty Line families.

• Availability of assured healthcare at reduced financial risk through pilots of Community Health Insurance under the Mission.

• Provision of household toilets

• Improved outreach services through mobile medical unit at district level.

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)

• Postmyocardial infarction ( Dressler syndrome)

• Connective tissue diseases - Systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis

• Radiation therapy

• Iatrogenic - After sternal biopsy, pericardiocentesis, transvenous pacemaker lead implantation or central line insertion

• Uremia

• Idiopathic pericarditis

• Complication of surgery at the esophagogastric junction

• Pneumopericardium (mechanical ventilation or gastropericardial fistula)

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.

With further fluid accumulation, the pericardial pressure increases

Phase

II Reduced cardiac output.

Phase III A further decrease in cardiac output (due to equilibration of pericardial and left ventricular filling pressures)

1. 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.

2. Orthostatic syncope: Caused by rising rapidly from a reclined position, 30% in elderly
   The use of antihypertensive and antidepressant medications may contribute to orthostatic syncope.

3. Carotid sinus syncope (carotid sinus syndrome): Caused by a sudden loss of consciousness due to compression of the carotid sinus. It can be caused by turning the head to one side or wearing clothing or jewelry too tight on the neck.

4. Situational syncope: Number of normal activities; urinating, coughing, swallowing and defecating, etc. it can be both vasodepressor syncope and vasovagal syncope.Conditions associated with situational syncope include lung diseases, BPH, bladder obstruction, esophageal disorders and constipation.

5. Cardiac syncope: Caused by a sudden reduction in cardiac output Patient with cerebrovascular disease, anemia, coronary artery disease or heart valve disease are prone.

6. Idiopathic syncope: In most of these cases, the syncope is a singular episode from which the patient recovers quickly and suffers no long-term damage.

7. Local syncope: is not a loss of consciousness. It is when an area of the body becomes numb and/or white from lack of blood flow. “Local” refers to the fact that it is only occurring in a section of the body.

• 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.

• Cardiac outflow obstruction: Sudden-onset syncope with little or no prodrome. e. g. cardiac murmur (Young athletes)

• Acute MI or an aortic dissection.

Noncardiac syncope:

• Vasovagal syncope: standing position & precipitated by fear, emotional stress, or pain

• Orthostatic syncope: Dehydration and decreased intravascular volume

• Neurologic syncope: preexisting bilateral vertebrobasilar insufficiency. Circulation is obstructed briefly from the reticular activation system in the brain stem, resulting in loss of consciousness
  

1. Hypovolemia: Hemorrhage, blood loss, insufficient fluid intake- as in starvation, excessive fluid losses from diarrhea or vomiting, excessive use of diuretics etc.



2. Decreased cardiac output: despite normal blood volume, due to severe congestive heart failure, large myocardial infarction, or bradycardia, Beta blockers can cause hypotension



3. 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



4. Others causes: adrenal insufficiency, pregnancy, prolonged bed rest, poisoning, toxic shock syndrome, blood transfusion reactions etc.

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:

1. Benzodiazepines are used for amnesia.

2. Barbiturates or narcotics are used as sedatives to relieve anxiety.

3. Anti-cholinergics are used to reduce secretions and prevent bradycardia.

(Note: these are being used before anesthesia)

Intraoperative Anesthesia:

5 components used during anesthesia, (with drugs that best carry out that function next to it):

1) Amnesia -- Benzodiazepines

2. Analgesia -- narcotics

3. Anesthesia – barbiturates (sodium pentathal), amidazols (atomidate), phencyclidine (ketamine), phenolic compounds like propofol (diprivan)

4. Muscle relaxation – neuromuscular blocking agents

5. Hemodynamic stability

1)Benzodiazepines given IV can work as anesthetic. It can also be used as an antiseizure med, along with being a great amnestic, and good sedative.These drugs include diazepam (Valium), midazolam (Versed).and narcotics s as well, all with some effect on BP. Depending on the patient, you choose a drug that best suits your needs for the patient.

2) Narcotics classically bind opioid receptors. Morphine is the classical example. They are agonists to opioid receptors. There are several classes of opioid receptors, being mu1, mu2, kappa, delta, and sigma. Depending on relative binding, you may see variations in respiration depression, analgesia, nausea, vomiting, and other side effects associated with opioids.

Meperidine (Demerol), fentanyl, sufentanil, alfentanil, and remifentanil are all opioids. Remifentanil is a short acting opioid. The mainstays are still morphine and fentanyl. Sufentanil is newer. 100 mg of (Demerol) = 10 mg morphine. 10 mg of morphine = 100 g of fentanyl = 10 g sufentanil. As a narcotic agonist, fentanyl is about 10 times more potent than morphine. Sufentanil is probably about 100 times more potent than morphine.

While morphine induces histamine release, and affect blood pressure, these newer drugs are cardio-stable. Patients on cardiac anesthetic procedures probably have a narcotic like fentanyl or sufentanil. Respiratory function is not as important in these patients because we’re breathing for them with respirators

3) Barbiturates The newer drugs generally bring a patient rapidly to a level 3 or 4, because they essentially stop breathing, this is not a problem because when we use positive pressure on ventilation.

Examples include sodium thiopental and methohexital (brevital). They are rapid acting intravenous agents causing significant respiratory (and sometimes cardiac) depression. Sodium pentathal is unique in that it does not cause seizures. It raises seizure threshold. Methohexital will decrease seizure threshold. For these reasons, in a patient with status epilepticus or if there is a need to intubate a patient who is seizing, sodium pentathal is used.

All barbiturates are a derivative of barbituric acid, which is a 5 carbon ring structure. Depending on the orientation of the side groups, you can have thiobarbiturates (with sulfur containing), or oxybarbiturates, like methohexital

Neuromuscular blocking agents do not promote any sense of euphoria or well being or any other functions besides complete paralysis. They must be used in conjunction with drugs that cause amnesia or you will have a patient awake and paralyzed on the table.

4) Neuromuscular Blocking Agents. They’re also known as muscle relaxants, but that’s misleading because they cause paralysis. These aren’t the drugs you would receive if you went to see your family doc for back pain and he or she gave you something that made you drowsy and you wake up with your back feeling better. These drugs do not alter level of consciousness or perception of pain. You must support or control ventilation when using these drugs and monitor the anesthetic level because the patient can be lying there in pain and awake, just paralyzed (I personally ask that this be done to me when I’m undergoing surgery because I like to feel every cut of the knife.)They interrupt nerve impulses at the neuromuscular junction (NMJ).

Succinylcholine is the one depolarizing agent used. It causes a randomized firing of muscle fibrils before causing paralysis. Patients receiving succinylcholine may have fasciculations when they first receive the med.

Nondepolarizing agents go straight to flaccid (don’t you just love this word) paralysis. You will not see fasciculations. They are all basically curare type drugs. They differ slightly by onset of action, pharmacology, duration of action and the way in which they’re metabolized. There are two groups of nondepolarizers.

One group is like pancuronium. Pancuronium is an older drug that is still used that is steroid based. Vecuronium is also a steroid class drug. As an aside, Dr. Vitkun informed us that D-Cuvocurarium is the poisoned arrow drug that was used by aborigine’s to kill prey. They’d shoot an animal and chase it until it dropped from the poison causing paralysis.

Atracurium is a bis-isoquinolonium derivative. They have a very different type of metabolism. A newer drug called cis-atracurium undergoes Hoffman elimination, meaning that elimination is solely temperature and pH dependent. Therefore, this is the drug of choice for the patient in liver or kidney failure, or both. Dr. Vitkun then reminded us that inhaled anesthetics also do not need the kidneys or liver, as they are exhaled for elimination. Even though there is some metabolism, because of the time course, the majority of elimination is through exhalation.

5) Phencyclidines Ketamine, also known at parties as special K, is a very good amnestic and analgesic. It is a dissociative anesthetic agent. It maintains respiration. You can give an induction dose and maintain blood pressure and respiration to a large extent. It is termed a dissociative anesthetic and produces a fugue state, meaning that it separates mind from body (alright now were talking). These effects can occur because phencyclidines are more commonly known as PCP or “angel dust,” thereby facilitating those effects. Because of its near relatives, ketamine has now become a controlled drug in NY. It is also known as the “date rape drug.” It has veterinary use. Interestingly, animals are LESS sensitive to ketamine than us weakly humans. This is probably in relation to how it works in the brain. It is a good drug for trauma and for asthmatics.

Negatives are the abuse potential and “emergence delirium.” “Emergence delirium” is the “medicalized” term for a “bad trip” akin to that experienced from PCP. It is in 10 – 15% of patients under Ketamine.

These drugs are used for the induction of anesthesia. Ketamine was most commonly used in children. They’re also used in trauma and burn patients to maintain blood pressure and respiration because they’re generally hemodynamically stable.