ECT used in psychiatry

1. ELECTRO CONVULSIVE THERAPY
PREPARED BY
Mrs. Divya Pancholi
M.Sc. (Psychiatric Nursing)
Assistant Professor
SSRCN, Vapi

2. OUTLINE
DEFINITION OF ECT
PURPOSE
HISTORY
MECHANISM OF ACTION
TYPES OF ECT
INDICATIONS
CONTRAINDICATIONS
COMPLICATIONS
SIDE EFFECTS
PRE-ECT INVESTIGATIONS
ECT ROOM-EQUIPMENT &
MEDICATIONS
ECT TEAM
ROLE OF NURSE

3. WHAT IS
ELECTROCONVULSIVE
THERAPY?
• Electroconvulsive
Therapy is the
artificial induction of
a grandmal seizure
through the
application of
electrical current to
the brain.

4. PURPOSE
When the drugs are not
available
For quick recovery of patient
When the patient needs to
get back to work quickly

5. HISTORICAL
ASPECTS
• Insulin coma therapy was introduced in
1933.
• Von Meduna in 1934 used Camphor and
later used Metrazol to produce seizures
Difficult to control these seizures
Large morbidity and mortality
• ECT is type of somatic treatment first
introduced by Bini and Cerletti in April 1938.

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

7. TYPE OF SEIZURE PRODUCED
• Grandmal seizure- tonic phase
lasting for 10-15 seconds
• Clonic phase lasting for 30-60
seconds.

8. 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) and limbic system
(which may be responsible for mood
disorders), also involving the hypothalamus.

10. TYPES OF ECT
• Direct ECT: ECT is given in the absence of
anesthesia and muscle relaxation.
• Modified ECT: Here ECT is modified by
drug induced muscular relaxation and general
anesthesia.
FREQUENCY AND TOTAL NUMBER OF ECT
• Frequency: 3 times per week or as indicated.
• Total number: 6 to 10, up to 25 may be
preferred as indicated.

11. APPLICATION OF
ELLECTRODES
• Bilateral ECT: Each
electrode is placed 2.5-4 cm
above the midpoint, on a line
joining the tragus of the ear
and the lateral canthus of the
eye.

12. • Unilateral ECT:
Electrodes are placed
only on one side of
head, usually non-
dominant side (right
side of head in a right-
handed individual).

13. INDICATIONS
FOR ECT
Severe psychosis
(schizophrenia or
mania)
Severe
catatoniaMajor
depression
Organic
mental
disorders
Other
conditions

14. INDICATIONS
Major depression:
• With suicidal risk,
• stupor,
• poor intake of food and fluids;
• melancholia with psychotic features,
• unsatisfactory response to drugs or
where drugs are contraindicated or have
serious side effects.

15. CONTI….
Severe catatonia (functional):
• With stupor;
• poor intake of food and fluids,
• unsatisfactory response to drug
therapy, or when drugs are
contraindicated or have serious side
effects.

16. CONTI…
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.

17. CONTI….
Organic mental disorders:
 Organic mood disorders
 Organic psychosis
Other conditions:
• ECT is preferred to antidepressant therapy in some
cases,
• such as for patients with cardiac disease; when
tricyclics are contraindicated because of the potential
for dysrhythmias and congestive heart failure; and for
pregnant women, in whom antidepressants place the
fetus at risk for congenital defects

18. CONTRAINDICATIONS
Absolute:
• Raise ICP (intracranial pressure)
Relative:
• Cerebral
aneurysm

19. • Cerebral hemorrhage
• Brain tumor

20. • Acute myocardial
infarction • Congestive heart
failure

21. • Pneumonia
• Retinal
detachment

22. COMPLICATIONS
• Life-threatening complications of ECT are rare.
• ECT does not cause any brain damage.
• Fractures can sometimes occur in elderly patients
with osteoporosis.
• In patients with a history of heart disease,
dysrhythmias and respiratory arrest may occur.

23. SIDE EFFECTS
• Memory impairment
• Drowsiness, confusion, and restlessness
• Poor concentration, anxiety
• Headache, weakness/fatigue, backache,
muscle aches
• Dryness of mouth, palpitations, nausea,
vomiting
• Unsteady gait
• Tongue bite and incontinence

24. PRE-ECT
INVESTIGATIONS
• Detailed history and physical examination
• Blood Pressure for Hypertension
• Check for loose teeth
• Fundus Examination
• ECG
• Liver Function Tests
• Sr.Electrolytes

25. ECT ROOM -
MEDICATIONS
• Thiopental Sodium
• Succinyl-choline
• Atropine / Glycopyrrolate
• Diazepam
• Anti-arrhythmic drugs
• Anti-anaphylactic drugs
• Nitroglycerine
• I.V. Fluids

26. ECT ROOM-EQUIPMENT
• ECT machine • ECG Monitor

27. • Intubation set
• Suction Apparatus

28. • Defibrillator
• Bite-blocks, Airway,
Electrode Jelly

29. • EEG Monitor
• Pulse Oxymeter

30. ECT TEAM
• Psychiatrist
• Anesthesiologist
• Trained nurse

31. ROLE OF NURSE
A)Pre treatment evaluation:-

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

33. • Withhold night doses of drugs, which increase
seizure threshold like Diazepam, barbiturates and
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 and tight clothing should be
removed from the patient’s body.
• Empty bladder and bowel just before ECT.
• Administration of Inj. Atropine 0.6mg IM or SC 30
minutes prior ECT, or Iv just before ECT.

34. B) Intra procedure care:-

35. • Place the patient comfortably on the ECT
table in supine position.
• Stay with the patient to allay anxiety and
fear.
• Assist in administering the anaesthetic agent
(thiopental sodium 3-5mg/kg body weight)
and muscle relaxant (succinylcholine 1
mg/kg body weight).
• Since the muscle relaxant paralyzes ll
muscles including respiratory muscles,
patent airway should be ensured and
ventilatory support should be started.

36. • Mouth gag should be inserted to prevent possible
tongue bite.
• The places(s) of electrode placement should be
cleaned with normal saline or 25% bicarbonate
solution, or a conducting gel applied.
• Monitor voltage, intensity and duration of
electrical stimulus given.
• Monitor seizure activity using cuff method.
• 100% oxygen should be provided.
• During seizure monitor vital signs, ECG, oxygen
saturation, EEG, etc.
• Record the findings and medicines given in the

37. C) Post procedure care:-

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