brief pulse ect

beginning in the late 1970, the brief pulse waveform replaced the sine wave stimulus in ect in
most countries. Like the sine wave stimulus, the brief pulse waveform is bidirectional ( has
alternating positive and negative phases).

However, as opposed to the continuously undulating sine wave, the brief pulse consist of a
series of instantaneously rising and falling rectangular pulses of current, with adjacent pulses
separated by brief periods of no electrical activity.

Brief pulses are characterized by four stimulus parameters, pulse width, frequency, duration,
and peak current.

The duration of each pulse is referred to as the pulse width, which is measured is
milliseconds (thousandths of a second).

Pulse frequency, by convention, is defined in terms of pulse pairs per second, although it is
common practice to use the same unit of measure, hertz, as used for the sine wave.

The actual number of pulses per second is twice the frequency. In the example shown in,, a
brief pulse frequency of 60 hertz would be associated with 60 positive and 60 negative
departures from the baseline each second during the passage of the stimulus.

Duration is defined as the length of the entire series of pulses delivered, and is measured in
seconds. It is functionally the same as the time elapsed between the first and last pulse in the
series.

The final stimulus parameter is peak current, which is the maximum intensity of each pulse,
measured from the zero baseline, in amperes.

Ultra – brief pulse ect

Beginning in the late 1990, renewed interest has been shown in the so-called ultra-brief
stimulus waveform. Operationally, a brief pulse has a pulse width of 0,5-2,0 ms, whereas the
width of an ultrabrief pulse is less than 0,5 ms.

The electrical stimulus

Seizure threshold

Seizure threshold is the total amount of electricity necessary to induce a seizure and, as
discussed in vchapter 5, clinical applications is a parameter that is integral to stimulus dosing
in clinica practice. The physiological efficiency of the brief pulse stimulus in acctivating
brain neurons is more optimal than the sine wave because of its rapid rise and fall. In that
regard, its relatively short on time is analogous to that of endogenous neuroelectrical signals
within the brain- that is, action potentials. For this reason, evoking a generalized seizure
using a brief pulse device typically requires much less overall stimulus intensity than does a
sine wave stimulus. Theoretically, a similiar situation should exist in regard to ultra-brief
pulses, with the ultra-brief pulses being even more efficient in terms of neuronal excitation,
and thereby associated with a lower seizure threshold than brief pulses.

Current, voltage, and impedance

All electrical signals can be characterized by three primary variables, current, voltage, and
impwdance. In a physical sense, current is the number of electrons per second flowing
through a circuit. In this case, the circuit is made up of the ect machine, the stimulus cables,
the stimulus electrodes, and the patient’s head. Voltage is the force that drives the flow of
electrons during the stimulus. It is the push of the system. Impedance is a measure of the
obstacle to the current flows. It is the level of resistance to be overcome. In ect, the terms
impedance and resistance can be used interchangeably, because other factors potentially
involved in impedance-that is, capacitance and inductance-are not major contributors in ect.
The greater the resistance (or impedance), the greater the push (or voltage) required for the
fixed flow of electrons. In practical terms, a higher resistance is most often encountered in ect
with poor stimulus electrode contact, which requires a higher voltage to deliver a given
current level. Conversely, the lower the impedance, the less push or voltage required to move
a fixed current. The relationship among current, voltage, and resistance is called ohm’s law
and expressed in the equation.

Current = voltage/ resistance

Where current is measured in amperes (A) or milliamperes (mA), voltage is measured in

volts (V), and resistance (impedance) is measured in ohm’s.

Mode of stimulus delivery

In addition to the type of waveform used, ect devices differ in whether they administer the
stimulus via a constant current or constant voltage. If we aplly ohm’s law to the
administration of the electrical stimulus, we find that ect devices must allow the user to set
either current (constant-current device) or voltage (constant-voltage device). In either case,
the other measure of intensity varies with resistance, according to ohm’s law. Because current
is now recognized as being of greater physiological importance than voltage in ect, constant-
current devices are preferable because they allow the user a greater control over stimulus
intensity. In other words, with a constant-current device, such as the ect machines presently
marketed in the united states, the practitioner predetermines the amount of current the patient
will receive. Using the above equation for ohm’s law, the actual amount of current delivered
(in milliamperes) would theoretically remain fixed, with any variation in impedance (ohm’s)
being reflected by a proportional change in voltage while the current remains fixed. As an
example, a doubling in impedance from 150 to 300 would not effect the amount of current
(800mA) delivered. However, again using ohm’s law, the voltage would also double from 120
to 240 V. In practice, the ability of constant-current ect devices to maintain current at a
constant level breaks down when the impedance is grossly elevated (due to extremely poor
stimulus electrode contact). In such cases, the devices limit voltage output as a safety feature
(discussed in the following section).
Practical considerations regarding impedance

As is evident in the previous discussion, the electrical impedance during the passage of the
stimulus current is a very important measure. It can differ substantially across patients, and it
can vary from treatment to treatment in the same patient. The primary source of impedance,
as monitored during an ect treatment, is the scalp tissue that underlies the stimulus electrodes.
Because the skull is associated with extremely high intrinsic impedance, most of the electrical
stimulus current is shunted across the scalp tissues between the electrodes without ever
passing through the brain. As a result, only a fraction of the stimulus current actually enters
the brain unless a low-impedance pathway to the brain exists. For this season, stimulus
electrodes should never be placed over or adjacent to a defect. Because of the current’s
shunting across the scalp, the amount of current entering the skull is much less than that
present at the stimulus electrodes. In addition, this lower amount of current is spread over a
large surface area, so that the current density-that is, the amount of current per square
centimeter-is further diminished. The electrical stimulus is attenuated even further during its
passage through the skull, because of the large voltage drop that takes place across that
structures high impedance. All of these effects result in the fact that at the level of the brain
substance itself, both current intensity and voltage are markedly lower than at the stimulus
electrodes, such that a much weaker electrical current passes through neurons. This fact
should not be suprising because sometimes even a high-intensity stimulus delivered by the
ect device is insufficient to induce the level of neuronal activation necessary to gererate
seizure activity.

A too-low scalp impedance is associated with an increased scalp shunting of current, a lower
proportion of current entering the brain, and therefore diminished effectiveness in producing
a seizure. This situation can occur when the ect electrodes are placed too closer together or
when a cconducting medium, such as sweat, saline, or electrode gel, forms a low-impedance
pathway (short circuit) between the electrodes. More commonly, the impedance is too high.
This situation can occur when the stimulus electrodes are in poor contact with the skin,
causing the current to flow through a much smaller area. Because of the associated voltage
limiting by the device, this situation also makes it less likely than an effective stimulus will
be delivered and raises the theoretical risk of a skin burn ( although this would be extremely
unlikely with present devices).

Table 4-1 summarizes the causes of variations in impedance. To estimate whether impedance
during the passage of the stimulus current will be too high or too low, brief pulse devices in
the united states incorporate a self-test procedure. This feature involves the passage of a very
low current through the entire electrical circuit pertinent to ect (cable. Leads, electrodes, and
patient), allowing an estimation of impedance prior to stimulation. This low current is well
below the patient’s perceptual threshold, even if fully awake and alert. The impedance to this
small current is typically much greater than that encountered during the actual stimulus. This
defference is due to the fact that the impedance of the scalp tissue underlying the stimulus
electrode is voltage sensitive and drops virtually instantaneously during the passage of the
stimulus current. For this season, the impedance during the stimulus current is termedthe
dynamic impedance ( relating to the change that occurs during the passage of the stimulus
current), and the impedance during the self-test procedure is termed the static impedance
(reflecting the baseline impedance state). Typical dynamic impedance is around 220 (range
120-350), whereas typical static impedance is approximately 350-2000 for most devices
(range 300-3000). Impedance are higher for woman than for man and the greater for
unilateral stimulus electrode placement than for bilateral placement. Because impedance is
also inversely proportional to stimulus electrode size (surface area in contact with the scalp),
impedance are lower in the united states, where ect devices have stimulus electrodes 2 inches
in diameter, than in some other countries where stimulus electrodes are smaller.

As noted earlier, a frequent cause of markedly elevated stimulus intensity is inadequate

coupling of the stimulus electrodes to the scalp (caused, by insufficient preparation of the
scalp, insufficient use of electrode gel, particularly when hair is in the way, or too little
pessure in the application of the stimulus electrodes to the scalp). Another cause a very high
static impedance is the failure to connect the stimulus cable to the stimulus electrodes or the
loss of such a connection. If the static impedance is too high (>3000 with somatics thymatron
system IV and DGx or MECTA spECTrum ect devices, or failure with the MECTA SR and
JR devices), the electrode cables and the electrode application should be checked. The static
impedance should then be rested to ensure safe treatment. The MECTA spECTrum provides a
continous and automatic determination of static impedance, whereas the Thymatron devices
and the MECTA SR and JR devices require manual triggering of the static impedance
measurement. Therefore, the self-test procedure with the latter devices should be assesed bear
in time to actual stimulus delivery (although additional testing prior to that time is often
performed to ensure that the static impedance is within range at beseline).

Total amount of electricity delivered with ECT: charge and energy

For various reasons, being able to describe the total amount of stimulus intensity delivered, in
the form of a single composite intensity measure, is desirable. Such a measure, for example,
will allow overall stimulus dose to be represented by a single number. Two such composite
measure are charge and energy, both of which are automatically calculated by the present
generation of U.S. ECT devices. The first of these measure, chargem, represents the product
of the amount of current in a single pulse and the number of pulses delivered in the series,
and is measured in millicoulombs (mC). The amount of current in a single pulse is the
product of peak current (in amperes) and pulse width (in milliseconds), whereas the number
of pulses is the product of twice the frequency (in hertz) and duration (in seconds).

As an example, if one has a stimulus characterized by 0,5-ms pulse of 0,8-A intensity and a
frequency of 70Hz, delivered for a duration of 3 seconds, the charge is 0,5x0,8x2x70x3=168
mC.

Energy, in the context of ECT stimulus dose, is defined as the product of voltage and current
over the entire stimulus duration. With a contstan-current ECT device, using Ohm’s law to
relace voltage with the product of current and dynamic impedance. Because dynamic
impedance is not known until after passage of the stimulus, energy, as opposed to charge, is
not predictable prior to the stimulus. For this and other reasons, charge is the preferred means
of expressing total stimulus dosage.
Device characeristics stimulus parameter ranges, and maximum output charge and energy
(assuming a dynamic impedance of 220) are given in table 4-2 for the present generation of
ECT devices made in the united states as of desember 2008. Figure 4-2 provides photographs
of examples of these devices. Each of these devices provides the user wit a printout of the
pertinent electrical output information regarding the ECT stimulus, including both static and
dynamic impedance.

Bab 5