ELECTROCONVULSIVE THERAPY

PRESENTED TO: PRESENTED BY:

MRS ANUREET MAHAK THUSOO
NURSING TUTOR MSc 1 s t Yr.
DMCH
 INTRODUCTION

Electro convulsive therapy is also known as electroshock, is well

established controversial psychiatric treatment in which seizures are
electrically induced in anaesthized pati ents for therapeuti c eff ect.

In april 1938, carletti and bini (neuropsychiatrists) introduced ECT

technique.

In 1950, von medona modifi ed ECT procedure

 DEFINITION

 Electroconvulsive therapy is arti fi cial inducti on of a grandmal

seizure through the applicati on of electric current to the brain, the
sti mulus is applied through electrodes which are placed either
bilaterally in the fronto-temporal region or unilaterally on the non-
dominant side
OR
 ECT consists of passing electric
current through brain’s temporal lobe
to produce seizures aft er which brain
acti vity comes to normal
 INDICATIONS

Depression
Mania
Schizophrenia

Others-
Anorexia nervosa
Early morning insomnia
OCD
Post partum psychosis
 PREFERENCE OF ECT OVER
OTHER TREATMENTS

It is normally off ered when

Several medicati on tried but not helped
Side eff ects of anti depressants are too severe
fi nd ECT eff ecti ve in past
Pati ent has suicidal att empts
Pati ent does not eat or drink anything
 CONTRAINDICATIONS

ABSOLUTE RELATIVE
 ABSOLUTE

1. Rapid intra cranial pressure

2. Space occupying lesion in frontal cortex
3. Subarachnoid hemorrhage
 RELATIVE

1. Acute myocardial infarcti on

2. History of cerebral infarcti on
3. Fractures, fever
4. Cardiac arrhythmias
5. Hypertension
6. Pneumonia
7. Bronchial asthma
8. Aneurysm
9. Bleeding disorders

NOTE- ECT in pregnancy[2trimester] and old age are not

contraindicated.
 TECHNIQUE

The technique used for ECT administrati on are of two types:-

1. Direct ECT:-
 It is given in the absence of muscle relaxant and general
anesthesia.
 Only atropine sulphate is administered I/V or S/C or I/M half
an hour before treatment (it prolongs the period of
disorientati on aft er seizures and inhibits vomiti ng)
 Minor tranquillizer like COLMPOSE is also used.
 Grandmal seizures is induced by passing electric current
through the temporal lobe.
 MODIFIED ECT

ECT is modifi ed with the use of anesthesia, muscle relaxant and

oxygenati on.
The use of anesthesia is must to decrease anxiety and to
achieve maximum eff ect. It is used to modify force of
convulsion and to avoid complicati ons like bone fracture. It is
used in pati ents who are recovering from heart conditi ons.
 DRUGS USED IN ECT

DRUG DOSE ACTION

ATROPINE 0.6-1mg/kg Anticholinergic

PROPOFOL 0.75mg/kg Anaesthetic agent

THIOPENTAL 150-250 mg Anaesthetic agent

SUCCINYL CHOLINE 0.5-1.5mg/kg Muscle relaxant

PHENOBARBITAL 50-100mg Sedative

 ATROPINE

 It is given IV before the treatment or given S/C or I/M 30

min before treatment.
 It is given to decrease oral secreti ons and to prevent vagal
sti mulati on during ECT which causes cardiac arrest
 ANESTHETIC AGENTS

Propofol and thiopentone

 Thiopentone decreases the durati on of seizures.
Preparati on of thiopentone:- Dissolve 20ml NS in a vial of
500mg, it will be 25mg/ml and then draw in 10 ml syringe, and
give 2.5mg/kg.
 MUSCLE RELAXANTS

Succinylcholine is a depolarizing blocking agent, it’s administrati on is

followed by muscle fasciculati on which starts from above to
downwards, when the fi ne twitching movements disappear it is a
ti me of muscle relaxati on. It reduces intense muscle contracti on
associated with ECT
 MUSCLE FASCICULATION

 A B.P cuff is applied on one upper extremity and then succinyl-

choline is administered and then electric shock is given,
the seizure appears in
that extremity from upward
to downward.
A mouth gag is inserted in between teeth to prevent tongue bite
during the convulsion and pressure applied on mandible .
 PLACEMENT OF ELECTRODES

The electrodes (U shaped in most equipment) is moistened

with saline or 25% bicarbonate and are applied on head.
According to applicati on of electrodes it is of two types:-
Bilateral ECT
Unilateral ECT
 BILATERAL ECT

 Most commonly used

 Involves the placement of electrodes on bitemporal region
 An imaginery line is drawn from outer canthus of eye to
the tragus of ear.
 Midpoint of imaginery line is
located and electrode placed
(2.2 -4)cm above the
midpoint.
 UNILATERAL ECT

Electrodes are placed on one side of the head usually on the

non dominati ng side
Unilateral ECT is bett er with lesser side eff ects parti cularly
those of memory impairment
AMOUNT OF ELECTRICIT Y USED IN ECT

Voltage 70-150 volts Mean= 110 volts

Current 200-1600 mA Mean = 1000 mA

Duration 0.1- 1 sec Mean = 0.6 sec

 REFLEXES

 In Tonic phase
 Bleparospasm- a tonic spasm of eyelid muscles is
observed when current is applied.
 Mild grimace

 In Clonic phase
 Babinski refl ex-slow planter fl exion during tonic
phase and fi ne movements of toes in clonic phase
 Planter fl exion
Phases Happening Duration Reflexes

Tonic Muscle 10 sec Blepharospasm or

contraction mild grimace

Clonic Convulsions 25 sec Babinski , plantar

flexion,
 NUMBER AND FREQUENCY

 Depression:- Pati ent show response aft er few ECT and peak
response aft er 10-12 ECT.

 In Bipolar disorders(manic type) Schizoaff ecti ve or

catatonic schizophrenia peak response is shown aft er 5-10 ECT.

 In chronically ill schizophrenia peak response is shown aft er20-25

treatment.
ECT is given 3 ti mes a week the frequency of treatment can
be reduced if pati ent show a severe confusional state, in suicidal
cases it can be given on daily bases.
 COMPLICATIONS

 Aff ect on cogniti on and memory:-

1. Amnesia
 Retrograde
 Anterograde
2. Memory loss and confusion
3. Learning capacity improves though there is
impairment in retenti on of memory
 COMPLICATIONS

Fractures and dislocati ons

Headache
Fear due to unpleasant experience
Backache
Injury to mouth and tongue
 ECT TRAYS

1. Vital sign tray

A big tray
BP apparatus
Stethoscope
Kidney tray
2 bowl
Thermometer
2. ECT
A big tray
Kidney tray
2 bowl
Injecti on tray
Electrodes
Jelly
Zelco
Adhesive tap
3. Emergency
Ambu bag
Tongue depressor
Mouth gag
Torch
ET tube
Stylte
Laryngoscope
4. Sucti on tray
Sucti on cathether
Sterile container
Kidney tray
Bowl
Gloves
5. O2 tray
O2 mask
Kidney tray
Bowl
 PRE- TREATMENT EVALUATION

 Explanati on of procedure
 Informed consent
 Detailed medical and psychiatric
history
 General and systemic physical
examinati on
 Routi ne laboratory investi gati ons (Hb, ESR,urine
routi ne, ECG, chest X ray)
 Others like EEG and plasma pseudo cholinesterase (for
those who receive succinyl-choline)
 ROLE OF NURSE

It is important that pati ent should not hear or see

anything before or aft er treatment.
In hospital setti ng where ECT is given
nurse should do set up which includes:-
Waiti ng room
Treatment room
Recovery room or aft er care room
 WAITING ROOM

 Room should be calm with dim lights and light color

of walls.
 Put some fl owers to give pleasant feeling to pati ent.

 There should be magazine

so that pati ent can divert his
mind and reduce anxiety.

 Lavatory should be att ached because pati ent needs to

empty his bowel and bladder before treatment.
 Nurse should be available to clear the doubts
regarding ECT.
 TREATMENT ROOM/ECT ROOM

 It should have low level bed with railings for comfort

of pati ent, railing should be well padded to avoid
injury to pati ent during convulsions.
o Arti cles required for ECT are:-
 ECT machine-check all the plugs are in working
conditi on
 NS to clean temporal region and also to dip
electrodes
 Endotracheal tube
 Sterile sucti on catheters
 Mouth wipes and cott on balls
 Emergency drugs
 CONTD….

 Sterile syringes 2cc,

5cc,10cc
 Sterile spirit swabs
 In lower shelf of trolley
put AMBU bag
 B.P apparatus
 Mouth gag-to avoid injury in mouth
 Tongue depressor
 Small pillow to put under pati ent’s back
 Kidney tray and paper bag
 RECOVERY ROOM

Once pati ent respond to painful sti muli he is

transferred to recovery room
A well padded fl oor bed should be kept ready
Observati on and monitoring of vital-signs
Mouth wipe to clear secreti ons
Extra clothes if pati ent spoils with urine or stool
•Nursing intervention before Purpose
•Giving ECT

[Link] all the investigations •To select a patient for ECT

(Hb, urine for sugar and
Ketones)

•Consent is taken for legal

2. Written consent from
protection. Explanation to
relatives to be taken. They
relatives will avoid them from
should be explained in
shock and fear of therapy.
detail, patient should not be
told as word current causes
fear.
3. Patient should be kept To prevent vomiting and
NPO(atleast 2 to 3 hrs) aspiration after ECT.

[Link] all metallic To prevent electric current

articles (watch, bangles etc.) passing through unwanted
areas.

[Link] artificial dentures To prevent it from dislodging

and blocking respiratory
tract.
[Link] lipstick, nail polish
or any other make up. To check for cyanosis.
7. Loosen the tight •To help in facilating respiration
clothes( necktie in men, blouse and meet any emergency.
in women).
•To enhance the effect of ECT
8. Replace long sedatives with
hypnotics
•To reduce his/her
[Link] patient to empty embarrassment after
his/her bowel and bladder treatment

[Link] pre-medication to •To reduce anxiety of patient

patient (atropine and calmpose and enhance effectiveness
)
•Prepare patient
[Link] the stretcher of patient psychologically that he is
to the waiting room proceeding for procedure
Nursing Intervention Purpose
during ECT
1. Patient is transferred To prevent injury well-
on a trolley from the padded bed is given and
waiting room to ECT ECT is given in supine
room and is placed position.
in well-padded
comfortable dorsal
position or supine
position, small pillow
is kept under lumbar
curve.
2. Give short acting anesthetic To reduce his anxiety and
agent i.e. thiopentone cause less vigorous
2.5mg/kg and convulsions and thereby to
succinycholine .75-1.5 mg/kg. prevent complications.

[Link] padded mouth gag or

tongue depressor is placed To prevent biting of tongue
between the teeth. and injury to lips.

.
[Link] the shoulder To prevent fractures.
and arms tightly, restrain
the thigh with the help of
sheet.
To prevent jaw dislocation
5. Hyperextension of head and for patent airway
with support to chin by
the nurse.
6. Give few breaths of oxygen •To help the patient to
to patient. overcome phase of apnea
after convulsions.

[Link] electrodes dipped in •Concentrated saline is a

saline water or jelly for good conductor of electricity,
placing on temporal region. thereby facilities convulsions.

[Link] an observation of •To ensure that there are no

grandmal seizures. The initial stuns or sub shocks and the
tonic stage which lasts for10- treatment is successful
15 sec followed by
convulsions lasting for 25 to
30 sec.
[Link] suction To keep airway patent
immediately. and prevent patient
from aspiration
pneumonia.

[Link] respiration To prevent patient from

by giving oxygen by respiratory and cardiac
mask. complications.
Nursing intervention after Purpose
ECT
[Link] and record To prevent any respiratory
respiration, pulse and BP of and cardiac complications
patient

[Link] the railings and place [Link] prevent the patient

patient on a side lying fall, and to prevent
position, wipe the secretions. aspiration of secretions.

[Link] patient to recovery To make sure that patient

room only when she answer has come out of
simple question “open your unconsciousness.
mouth”
4. Record vital signs every To make early nursing
15 min , once patient is diagnosis of patient going to
stable record every 30 complications.
min till he recovers
completely.

5. Allow patient to sleep for To help the patient to

30 min to 1 hour. overcome physical exhaustion.

6. Reassure the patient. It helps to overcome

maladaptive behavior.

7. Reorient patient to ward To help patient to overcome

toilet and nursing station confusional state.
[Link] a note of any injuries To detect any type of fracture
or complaints of pain by the
patient-body pain headache.

[Link] patient to go for To give patient a sense of

shower bath and change well being and freshness.
clothes.
To meet the nutritional need
[Link] patient to take as he has not taken anything
clear tea followed by meals. since morning

[Link] the MMSE To check cognition

impairment.
[Link] patient to carry out
daily activites It helps to resume patient to
his work.
 SUMMARIZATION

Introducti on
Defi niti on
Indicati ons
Contraindicati ons
Types & techniques
Procedure
Complicati ons
Nursing care
 RECAPITULATION

[Link] ECT.
[Link] are the indications of ECT?

True or false
1. Succinylcholine is a anesthetic agent.
2. ECT can not be given in pregnancy.
3. Amount of current passed in ECT IS 200-1600mA.
THANK YOU