content will help to healthcare community including nursing students to understand the concept of electroconvulsive therapy

1. ELECTROCONVULSIVETHERAPY
AashishParihar
Lecturer
CollegeofNursing
AIIMS,Jodhpur

2. Definition
•Electro convulsive therapy is the induction of Grand-mal seizure through the
application of electrical current to the brain.
•An electric current is applied for a fraction of a second through electrodes
placed on the temporal region. This immediately produces two stage seizure or
convulsion (tonic and clonic stage).
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3. History
•ECT is a type of Somatic or physical therapy, first introduced by Ugo Cerletti,
Lucio Bini in 1938.
•Some of the other shock therapy were used earlier prior to ECT were as follows:
•Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist
Ladislas Von Medusa induced seizures with first camphor and then metrazol
(cardiazol).
•Insulin shock therapy was introduced in 1927 by Austrian-American
psychiatrist Manfred Sakel
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4. METHODS OF GIVING ECT
•ECT can be given by-
•Direct method
•Indirect method
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5. METHODS OF GIVING ECT
Direct method (Unmodified)
•The patient is administered atropine sulphate subcutaneously 0.6 mgm to 1.0
mgm, half an hour before the treatment or IV immediately before the treatment.
•Minor tranquilizer is also used.
•A Grand-mal seizure is induced in the patient by passing an electric current
through the temporal lobe.
•Atropine reduces vomiting.
•Immediately after the ECT treatment appropriate resuscitative and other
emergency management equipments and supplies are kept ready.
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6. METHODS OF GIVING ECT
Indirect method (Modified)
•Electroconvulsive therapy is modified with the use anesthesia, muscle
relaxants and oxygenation.
•This method of giving ECT is also known as indirect method.
•The use of anesthesia is necessary to alloy anxiety and achieve the maximum
effect.
•It is used to modify the force of convulsion and to avoid the complications like
fractures.
•Modified ECT is also used for the patients who are recovering from heart
condition.
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7. Drugs used during ECT
•Atropine Sulphate- 0.6 to 1.0 mgm to control salivation and vomiting
•Minor tranquilizer
•Ultra short acting depolarizing agent (muscle relaxant) succinylcholine 0.3ml to
0.5ml.
•A short acting barbiturate, methohexial sodium (Brevital sodium) or thiopental
(Pentothal) 5ml to 10 ml.
•Oxygen
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8. Placement of electrodes
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9. AMOUNT OF CURRENT
•The nature and range of stimulus intensity setting varies from device to device.
• 70-120 volt for 0.7 to 1.5 second will produce a convulsive effect.
•The actual amount of current passed during the treatment was found to range
between 200-1600 milliampheres.
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10. OBSERVATION OF PRODUCTION OF SEIZURE
• The production of Grandmal seizure is necessary for direct and indirect or
modified ECT.
•In direct ECT, the tonic phase that is muscle contraction last for 10 seconds
approximately.
•The clonic phase that is movement or convulsion last for 25 to 30 second.
•Then the patient goes in to relaxation phase.
•With the use of anesthesia in modified ECT, mild grimace or blephro-spasm, a
tonic spasm of the eyelid muscles, is observed when the current is applied.
• There is a slow plantar flexion during the tonic phase and fine movements of
the toes during the clonic phase.
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11. NUMBER AND FRQUENCY OF ECT TREATMENT
• There is no clinical justification for a fixed number of treatments, however,
patient with depression shows some sort of improvement after the first few
treatments.
•Response, from the patients with bipolar disorder, mania, schizoaffective
disorder or catatonic schizophrenia, is attained between 5 to 10 treatments.
•20-25 treatments may be required for chronically ill schizophrenic patients.
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12. Mechanism of Action
• The exact mechanism by which ECT affect a therapeutic response is unknown.
• Several theories exist, but the one to which the most credibility has been given
is the biochemical theory.
•A number of researchers have demonstrated that electric stimulation results in
significant increases in the circulating levels of several neurotransmitters.
These neurotransmitters include serotonin, norepinephrine, and dopamine, the
same biogenic amines that are affected by antidepressant drugs.
•Additional evidence suggests that ECT may also result in increases in
glutamate and gamma amino butyric acid (GABA).
•Other theories regarding ECT are tabulated as follows:-
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13. Mechanism of Action
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S.N. OBSERVED CHANGES SIGNIFICANCE
1
EEG CHANGES
Electrocerebral silence Defibrillator like effect i.e. healthy
functioning resumes after ECT
2
NEUROCHEMICAL CHANGES
Increased GABA
Increased CSF concentration of acetyl choline and down regulation of
cortical muscarinic receptors
Causes elevated seizure threshold level;
anticonvulsant action reduces kindling
in limbic structure
May be partially responsible for memory
impairment
3
NEUROENDOCRINE CHANGES
ECT causes release of hypothalamic and pituitary hormones,
including prolactin
Release of an antidepressant hormone
from the hypothalamus
4
BLOOD-BRAIN BARRIER CHANGES
Increased cerebral blood flow and blood-brain barrier permeability May facilitate entry of the co-
administered psychotropic drugs

14. ELECTROCONVULSIVETHERAPY
Indications
•Major depressive episodes is a
primary indication
•Involutional melancholia
•Psychotic depression
•Unipolar bipolar depression
•Depression of old age
•Post partum depression
•Mania
•Catatonia
•Schizophrenia when not
responding to other therapies
•Other responsive groups to ECT
treatment are patient with-
•Premorbid personality
•Stupor
•Previous depressive episode
•Paranoid delusion
•Anorexia
•Early morning insomnia
•Weight loss
•Lack of concentration
•Ideas of guilt and worthlessness
•Suicidal thought and suicidal attempts

15. Contraindications
• Absolute contraindication for ECT-
patient with increased intracranial pressure, including tumors, hematomas, and
subarachnoid hemorrhage because these may lead to neurological deterioration
with ECT.
• Relative contraindication-
Cerebral aneurysm
Acute myocardial Infarction
Congestive heart failure
Pneumonia or aortic aneurysm
Retinal detachment
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16. COMPLICATION AND ADVERSE EFFECTS
•Temporary memory loss
•Fracture and dislocation
•Other complaints of patients due to ECT
Headache, backache, apnea, painful mastication, injury to the mouth and
tongue.
Stuns or subshock occur due to an insufficient current applied to the patient
which does not lead to a full convulsion stage.
It sometimes produces cardiac irregularities, respiratory distress and collapse.
Confusion after subshock is more marked than a major fit due to ECT.
If three subshock given in a day, the treatment should be stopped.
The next day ECT may be given with increased intensity of the current
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17. ARTICLES NEEDED FOR ECT:
Articles for the preparation of the patient:
•Pillows to put under the patient’s waist to prevent injury
•Mouth gag to prevent tongue bite and for patent airway
•Endotracheal tube and sterile suction catheter for suction of the respiratory tract
•O2 cylinder and AMBU bag for artificial respiration
Articles for the procedure:
•A trolley with an ECT machine in working order
•Jelly or normal saline for putting on electrodes as normal saline is good conductor of
electricity
•Emergency drugs and resuscitation tray
•BP apparatus, mouth wipe sterile syringes and spirit swabs.
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18. TEAM OF ECT:
•Psychiatrist
•Anesthetist
•ECT nurse
•Recovery room nurse
•ECT technician
•Nursing aids
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19. Role of Nurse
•Pretreatment nursing care
•Nursing care during the procedure
•Post treatment nursing care
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20. Role of Nurse
•Pretreatment nursing care
Obtain a written consent from the close relative after explaining the method of treatment and
risks for legal protection and as it prevents the fear of therapy.
Check that a thorough physical examination is completed including Hb estimation, ECG,
respiratory status etc.
Involve the family in the therapy as much as possible to reduce misconception and anxiety.
Communicate positive feelings about the procedure to the family and patient.
The patient should be kept NPO before treatment.
Remove lipsticks, nail polish and any other makeup prior to treatment to check for any
cyanosis.
Remove dentures or any other metallic jewelry before ECT.
Discourage cigarette smoking before procedure as it increases pulmonary secretion.
Instruct the patient to evacuate the bowel and bladder prior to ECT.
Ask the patient to not to oil the hair prior to ECT
Encourage the patient to maintain the personal hygiene.
Make sure that oxygen, Endotracheal tube, suction is accessible and in functioning condition.
Give premedication to the patient i.e. Inj atropine and Calmpose.
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21. Role of Nurse
•Nursing care during the procedure
Nurse should help in the transfer of the patient from trolley to the low level bed.
Place the patient in supine position and place a small pillow under the lumbar curve to prevent
injury.
Give a short acting anesthetic agent. Thiopental 0.25gm to 0.5gm IV, and succinylcholine 0.30mgm
to 0.50mgm.dose may vary patient to patient.
Place a well padded mouth gag in mouth or tongue depressor in between the teeth to prevent the
tongue bite during the seizure produced by the ECT.
Apply a light restrain on arms and shoulder to prevent the dislocation.
 Hyperextend the head with support to the chin to prevent the jaw dislocation and for patent
airway.
Give a few breath of oxygen to the patient to help the patient to overcome a phase of apnea faster
after convulsion.
Provide electrodes dipped in saline or with application of jelly for placing on the temporal region.
Make an observation of grand mal seizure. The presence of the initial tonic phase last for 10-15
seconds followed by convulsion lasting for 25-30 seconds. Then there is a phase of muscular
relaxation with Sertorius respiration.
Do suction immediately to keep patent airway and prevent the patient from aspiration pneumonia.
Restore oxygen by giving o2 by mask, if required.
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22. Role of Nurse
•Post treatment nursing care
Observe and record respiration, pulse and blood pressure of the patient to prevent
any respiratory and cardiac complication.
Put the railings and place the patient in side lying position, wipe the secretion.
Transfer the patient to the recovery room only if can answer the simple questions like
“what is your name, lift the hands up etc.” it ensures that patient has come out of the
phase of unconsciousness.
Record TPR and BP and the level of consciousness every 15 minute to make early
nursing diagnosis of the patient going into complication.
Allow the patient to sleep for at least half an hour to one hour to get relief from
physical exhaustion.
Reorient the patient for time, place and person to avoid the confusional status.
Reassure the patient to overcome his maladaptive behavior because research stated
that post ECT patient becomes highly suggestible.
Allow the patient to take clear liquid followed by breakfast if patient does not vomit.
Encourage the patient to carry out his daily activities of living.
Make observation of any changes.
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