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1. Notes by Neha Bhatt
Electroconvulsive Therapy
Presentation By Neha Bhatt
• Electroconvulsive therapy is a type of somatic treatment first introduced by Bini and
Cerletti in April 1938.
• From 1980 onwards ECT is being considered as a unique psychiatric treatment.
• Electroconvulsive therapy is the artificial induction of a grandma seizure through the
application of electrical current to the brain.
• The stimulus is applied through electrodes that are placed either bilaterally in the
fronto-temporal region, or unilaterally on the non-dominant side (right side of head in
a right-handed individual).
Parameters of Electrical Current Applied
• Voltage - 70-120 volts.
• Duration - 0.7-1.5 seconds
Type of Seizure Produced
• grandma! seizure-tonic phase lasting for 10- 15 seconds.
• clonic phase lasting for 30-60 seconds
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.
Types of ECT
• Direct ECT: In this, ECT is given in the absence of anaesthesia and muscular
relaxation. This is not a commonly used method now.
• Modified ECT: Here ECT is modified by drug induced muscular relaxation and
general
• anaesthesia.
Frequency and Total Number of ECT
• Frequency: Three times per week or as indicated.
• Total number: 6to 10; up to 25 may be preferred as indicated.
Application of Electrodes
• Bilateral ECT: Each electrode is placed 2.5-4 cm (1-1.5 inch) above the midpoint, on
a line joining the tragus of the ear and the lateral canthus of the eye.
• 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.
Indications
• Major depression: With suicidal risk; with stupor; with poor intake of food and fluids;
melancholia with psychotic features with unsatisfactory response to drugs or where
drugs are contraindicated or have serious side-effects .

2. Notes by Neha Bhatt
• Severe catatonia (functional): With stupor; with poor intake of food and fluids; with
unsatisfactory response to drug therapy, or when drugs are contraindicated or have
serious side-effects.
• Severe psychosis (schizophrenia or mania): With risk of suicide, homicide or danger
of physical assault; with depressive features; with unsatisfactory response to drug
therapy, or when drugs are contraindicated or have serious side-effects.
• Organic mental disorders:
• organic mood disorders.
• organic psychosis
• Other indications: ECT is preferred to antidepressant therapy in some cases, such as
for clients 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 foetus at risk for congenital defects.
Contraindications
A Absolute: • raised ICP (intracranial pressure)
B. Relative:
• cerebral aneurysm
• cerebral haemorrhage
• brain tumour
• acute myocardial infarction
• congestive heart failure
• pneumonia or aortic aneurysm
• retinal detachment
Complications of ECT
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.
Side Effects of ECT
• 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.
ECT Team
Psychiatrist, anesthesiologist, trained nurses and aides should be involved in the
administration of ECT.
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 and accessories, an anaesthetic
appliance, suction apparatus, face masks, oxygen cylinders with adjustable flow valves,
curved tongue depressors, mouth gags, resuscitation apparatus and emergency drugs.
There should be immediate access to a defibrillator.

3. Notes by Neha Bhatt
3. A well-equipped recovery rooms.
Role of the Nurse
a. Pre-treatment evaluation
• Detailed medical and psychiatric history, including history of allergies.
• Assessment of patient's and family's knowledge of indications, side-effects, therapeutic
effects and risks associated with ECT.
• An informed consent should be taken. Allay any unfounded fears and anxieties regarding
the procedure.
• Assess baseline vital signs.
• Patient should be on empty stomach for 4-6 hours prior to ECT.
• 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 0.6 mg atropine IM or SC
30minutes 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 and fear.
• Assist in administering the anaesthetic agent (thiopental sodium 3-5 mg/kg body weight)
and muscle relaxant (1mg/kg body weight of succinylcholine).
• Since the muscle relaxant paralyzes all muscles including respiratory muscles, patent airway
should be ensured and ventilatory support should be started.
• Mouth gag should be inserted to prevent possible tongue bite.
• The place(s) of electrode placement should be cleaned with normal saline or 25 percent
bicarbonate solution, or a conducting gel applied.
• Monitor voltage, intensity and duration of electrical stimulus given.
• Monitor seizure activity using cuff method.
• 100 percent oxygen should be provided.
• During seizure monitor vital signs, ECG, oxygen saturation, EEG, etc.
• Record the findings and 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 and restlessness.
• Take safety precautions to prevent injury (sidelying position and suctioning to prevent
aspiration of secretions, use of side rails to prevent falls).
• If there is severe post-ictal confusion and restlessness, IVdiazepam may be administered.
• Reorient the patient after recovery and stay with him until fully oriented.
• Document any findings as relevant in the patient's record.