ECT Guide: Indications, Techniques, Side Effects & Complications

PHYSICAL
THERAPY
MR. JAYESH PATIDAR
www.drjayeshpatidar.blogspot.com

CONCEPT…
• Physical therapies are treatment
approaches that use physiologic or
physical interventions to effect
behavioral change.
• The most common form of physical
therapies are: Electroconvulsive
therapy, light therapy, repetitive
transcranial magnetic stimulation
4/24/2013 www.drjayeshpatidar.blogspot.co

ELECTROCONVULSIVE
THERAPY

INTRODUCTION…
• Electroconvulsive therapy is a type of
somatic treatment, first introduced by Bini &
Cerletti in April 1938.
• From 1980 onwards ECT is being
considered as a unique psychiatric
treatment.

DEFINITION
• ECT is a type of somatic treatment in
which electric current is applied to the
brain through electrodes placed on the
temples of the patient. The passage of
an electrical stimulus of 70 to 120 volts
to the brain for 0.7 to 1.5 second to
produce a grandmal seizures.

MECHANISM OF ACTION
• The exact mechanism of action is not
known.
• One hypothesis states that ECT possibly
affects the catecholamine pathways
between diencephalon (from where seizure
generalization occurs) & limbic system
(which may be responsible for mood
disorders), also involving the
hypothalamus.

TYPES / TECHNIQUES / METHODS
OF ECT
1. Direct ECT
2. Modified ECT

1. Direct ECT:
• In this, ECT is given in the absence of
anesthesia & muscular relaxation.
• This is not commonly used method
now.

2. Modified ECT:
• In this, ECT is modified by drug-
induced muscular relaxation, general
anesthesia & oxygenation.
• Administer the anesthetic agent
(thiopental sodium 3-5mg/kg body
weight) & muscle relaxant (1mg/kg
body weight of succynylcholine)

PLACEMENT OF ELECTODES
• There are two types of administration:
1. Bilateral ECT
2. Unilateral ECT

1. Bilateral ECT:
• Each electrode is placed 2.5-4 cm (1-
1½ inch) above the midpoint, on a line
joining the tragus of the ear & the
lateral canthus of the eye.

2. Unilateral ECT:
• Electrodes are placed only on one side
of head, usually non-dominant side
(right side of head in a right-handed
individual).
• Unilateral ECT is safer, with much
fewer side-effects particularly those of
memory impairment.

PARAMETERS OF ELECTRICAL
CURRENT APPLIED
Standard dose according to American
Psychiatric Association,1978:
• Voltage – 70 – 120 volts
• Duration – 0.7 – 1.5 seconds

FREQUENCY AND TOTAL NUMBER
OF ECT
• Frequency: Three times per week
or as indicated.
• Total number: 6 to 10; upto 25 may
be preferred as indicated.

OBSERVATION OF PRODUCTION OF
SEIZURE
• The production of grandmal seizure is
necessary for direct & modified ECT.
• In direct ECT, the Tonic Phase that is
muscle contractions last for 10-15 second
approximately. The Clonic Phase that is
movement or convulsion lasts for 30 to 60
seconds approximately. Than patients goes
in to the Relaxation Phase. The physician
can see changes in ECG also

Count…
• In modified ECT, mild grimace or
blepharo-spasm ( a tonic spasm of the
eyelid muscle) is observed when the
current is applied. There is a slow planter
flexion (reverse Babinski's) during the
tonic phase & there are fine movements of
the toes during the Clonic phase.

INDICATIONS OF ECT
I. Major Depression:
- With suicidal risk
- With stupor; poor intake of food & fluids
- Melancholia with psychotic features
- Post-partum depression
- Unsatisfactory response to drugs or where
drugs are contraindicated or have serious
side effects

Count…
II. Severe catatonia (functional):
- With stupor; poor intake of food &
fluids
- Unsatisfactory response to drug
therapy, or when drugs are
contraindicated or have serious side
effects.
- When speedier recovery is needed

Count…
III. Severe psychosis (schizophrenia or
mania):
- With risk of suicide, homicide or danger
of physical assault
- Depressive features
- Unsatisfactory response to drug therapy,
or when drugs are contraindicated or
have serious side effects.

Count…
IV.Organic mental disorders:
- Organic mood disorders
- Organic psychosis

Count…
V. Other indications:
- Premorbid personality
- Previous depressive episode
- Paranoid delusion
- Anorexia
- Early morning insomnia
- Wight loss
- Lack of concentration
- Ideas of guilt & worthlessness
- Suicidal thought & suicidal attempts

Count…
- ECT is preferred to antidepressant therapy
in some cases, such as for patient with
cardiac disease; when tricyclics are
contraindicated because of the potential for
dysrhythmias & congestive heart failure; &
for pregnant women, in whom
antidepressants place the fetus at risk for
congenital defects

CONTRAINDICATIONS OF ECT
A. Absolute:
• Raised ICP
(intracranial
pressure)
B. Relative:
• Cerebral aneurysm
• Cerebral hemorrhage
• Brain tumor
• Acute myocardial infarction
• Congestive heart failure
• Pneumonia or aortic aneurysm
• Retinal detachment
• CVA
• Hypertension
• Thrombophelebitis
• bleeding disorder

SIDE EFFECTS OF ECT
• Memory impairment
• Drowsiness, confusion & restlessness
• Poor concentration, anxiety
• Headache, weakness/fatigue, backache,
muscle aches
• Dryness of mouth, palpitation, nausea, vomiting
• Unsteady gait
• Tongue bite & incontinence

COMPLICATION OF ECT
1. Fractures & dislocations
2. Complication in the respiratory system
3. Other complication

Count…
1. Fractures & dislocations:
 Most frequently the fracture & dislocation are
caused by muscular contraction due to ECT
 Compression fracture of vertebrae of dorsal area
between the 2nd & 8th usually 3rd , 4th & 5th
vertebrae is common.
 Fracture of femur & humerus occurs in young
muscular individuals.
 Dislocation of jaw is the most frequent
complication of the tonic phase.

Count…
2. Complication in the respiratory system:
 Apnea
 Respiratory arrest

Count…
3. Other complication:
 Headache, backache, painful mastication, injury
of mouth & tongue.
 Fear due to an unpleasant experience on
walking up after the treatment.
 Stuns & subshocks occur due to an insufficient
current applied to the patient which does not
result in a full convulsive stage. These
subshocks or stuns will sometimes produce
cardiac irregularities, respiratory distress &
collapse.

ECT TEAM
• Psychiatrist
• Anesthesiologist
• Trained nurses & aides

TREATMENT FACILITIES
There should be a suite of three rooms:
1. A pleasant, comfortable waiting room (pre-ECT
room).
2. ECT room, which should be equipped with ECT
machine & accessories, an anesthetic appliance,
suction apparatus, face masks, oxygen cylinders
with adjustable flow valves, curved tongue
depressors, mouth gags, resuscitation apparatus
& emergency drugs. There should be immediate
access to defibrillator.
3. A well-equipped recovery room.

ROLE OF THE NURSE
A. Pre-treatment Evaluation
B. Intra-procedure Care
C.Post-procedure Care

A. Pre-treatment Evaluation:
• Detailed medical & psychiatric history, including
history of allergies.
• Assessment of patients’ & families knowledge of
indications, side-effects, therapeutic effects &
risks associated with ECT.
• An informed consent should be taken. Allay any
unfounded fears & anxieties regarding the
procedure.
• Assess baseline vital signs.
• Patient should be on empty stomach for 4-6
hours prior to ECT.

Count…
• Withhold night doses of drugs, which increase seizure
threshold like diazepam, barbiturates &
anticonvulsants.
• Withhold oral medications in the morning .
• Head shampooing in the morning since oil causes
impedance of passage of electricity to brain.
• Any jewellery, prosthesis, dentures, contact lens,
metallic objects & tight clothing should be removed
from the patient’s body.
• Empty bladder & bowel just before ECT.
• Administration of 0.6 mg atropine IM or SC 30 minutes
before ECT, or IV just before ECT.

B. Intra-procedure Care:
• Place the patient comfortably on the ECT table in
supine position.
• Stay with the patient to allay anxiety & fear.
• Assist in administering the anesthetic agent
(thiopental sodium 3-5 mg/kg body weight) & muscle
relaxant (1 mg/kg body weight of succynylcholine).
• Since the muscle relaxant paralyzes all muscles
including respiratory muscles, patient airway should
be ensured & ventilatory support should be started.
• Mouth gag should be inserted to prevent possible
tongue bite.

Count…
• The place(s) of electrode placement should be
cleaned with normal saline or 25% bicarbonate
solution, or a conducting gel applied.
• Monitor voltage, intensity & duration of electrical
stimulus given.
• Monitor seizure activity using cuff method.
• 100% oxygen should be provided.
• During seizure monitor vital signs, ECG, oxygen
saturation, ECG, etc.
• Record the findings & medicines given in the
patient’s chart

C. Post-procedure Care:
• Monitor vital signs.
• Continue oxygenation till spontaneous respiration starts.
• Assess for post-ictal confusion & restlessness.
• Take safety precautions to prevent injury (side-lying position &
suctioning to prevent aspiration of secretions, use of side rails
to prevent falls).
• If there is severe post-ictal confusion & restlessness, IV
diazepam may be administered.
• Reorient the patient after recovery & stay with him until fully
oriented.
• Document any findings as relevant in the patient’s record.

LIGHT
THERAPY

CONCEPT…
• Light therapy sometimes called
phototherapy involves exposing the
patient to an artificial light source during
winter months to relieve seasonal
depression.
• The light source must be very bright,
full-spectrum light, usually 2,500 lux.

INDICATIONS
• Bulimia
• Sleep maintenance insomnia
• Seasonal depression

ADVERSE EFFECTS
• Nausea
• Eye irritation
• Headache

CONTRAINDICATIONS
• Glaucoma
• Cataract
• Use of photosensitizing medications.

NURSE’S ROLE
• The patient is instructed to sit in front of
the light at a distance of about 3 feet,
engaging in a variety of the other
activities but glancing directly into the
light every few minutes.
• The duration of administration is 1-2 hrs
daily.

REPETITIVE
TRANSCRANIAL
MAGNETIC
STIMULATION

REPETITIVE TRANSCRANIAL
MAGNETIC STIMULATION:
• Transcranial Magnetic Stimulation (TMS) or
Repetitive Transcranial Magnetic Stimulation
(RTMS) produces a magnetic field over the brain,
influencing brain activity.
• TMS increases the release of neurotransmitters &
downregulates bets-adrenergic receptors, thus
ameliorating depressive symptoms & other
disorders.
• Because TMS does not require anesthesia, it is
an attractive alternative to ECT if convulsive
evidence of its efficiency can be demonstrated.

Count…
• Some studies have suggested that it is as
effective as ECT in non-psychotic patients.
• Adverse effects include seizures in
previously seizure-free individuals,
headache, & transient hearing loss.
• Patient with metal implanted in their bodies
(for example, plates), pacemakers, heart
disease or increased intracranial pressure
should be carefully evaluated before
receiving TMS

Thank
You

ECT Guide: Indications, Techniques, Side Effects & Complications

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ECT Guide: Indications, Techniques, Side Effects & Complications