ELECTROCONVULSIVE THERAPY

INTRODUCTION
Somatic Therapies are treatment approaches that uses physiological or physical interventions to effect behavior change. The most common form of somatic therapy is ECT. It was first used as a treatment modality in 1934, to cure psychotic disorders by inducing convulsions.

HISTORY
1500 Parcelsus induces seizures by administering camphor by mouth to treat psychotic illness. 1934 Ladislaus Meduna begins the modern era of convulsive therapy by using IM injection of camphor for catatonic schizophrenia 1938 Lucio Cerletti and Ugo Bini conduct the first electrical induction of a series of seizures in a catatonic patient and produce a sucessful treatment response.

DEFINITION
ECT are also known as Electroshock or Shock Therapy. Electroconvulsive Therapy is a type of somatic treatment in which electric current is applied to the brain through electrodes placed on the temples of the patient

INDICATIONS
The main indications of ECT include 1. Depressive Illness ECT is effective in treating depression especially with somatic features, and psychotic symptoms. Severe Depression with suicidal risk Depressive Stupor Severe Pureperal Depression Depressive illness with nihilistic or paranoid illness

INDICATIONS Cont
Failure to respond to an adequate course of antidepressant In elderly where the ECT is safer than drugs Inability to take drugs e.g. Depression in First trimester of Pregnancy or Physical illness

INDICATION Cont
2. Schizophrenia ECT produces greater early symptomatic relief than the neuroleptics. The main indications of ECT in Schizophrenia are, Excitement Stupor Purperal Schizophrenia Schizophrenia episodes in first trimester of pregnancy

INDICATIONS Cont
3. MANIA The main indication of ECT in mania are Excited or Uncooperative behavior Bipolar Mood disorder with mixed features 4. POST PARTUM PSYCHOSIS 5. SCHIZOAFFECTIVE DISORDERS 6. PSYCHOSIS IN 1st TRIMESTER OF PREGNANCY

CONTRAINDICATIONS
ABSOLUTE RELATIVE

The only absolute CI is the presence of raised ICP

These includes Recent MI Severe Hypertension Cerebero vascular Accident Severe Pulmonary Disease Retinal Detachment Pheochromocytoma

MODE OF ACTION
The exact MoA of ECT is unknown, various hypotheses suggest different MoA. 1. The passage of current results in production of generalized tonic clonic seizures lasting at least 25 30 sec. 2. ECT affects the catecholamine pathways between Diencephalon and limbic system also involving hypothalamus. As ECT increases threshold for further seizures, it may paradoxically act as an anticonvulsant.

CLINICAL GUIDELINES FOR ECT

Pre treatment Evaluation Pre Medications Electrodes Placements Electrical Stimulus Induced Seizures Monitoring Seizures Failure to Induce Seizures Number and spacing of Treatment

PRE TREATMENT EVALUATION

Pre Treatment evaluation should includes 1. Standard Physical Examination 2. Neurological Evaluation 3. Complete Medical History 4. Chest X Ray 5. Electrocardiogram 6. Dental Examination 7. CT & MRI ( Seizure Disorder) 8. X Ray of the Spine (Spinal Disorder) 9. Blood and Urine Chemistries

PRE MEDICATIONS
Patients should be kept in NPO for 6 Hrs. IV line should be established A Bite block is inserted into the mouth just

before administering ECT. 100 % Oxygen is administered at a rate of 5 Liters per minute Emergency equipments for establishing airway should be kept near for immediate access if need arise

Pre Medications Cont

Anticholinergic Drugs Anesthesia Muscle Relaxants

Muscarinic

MUSCARINIC ANTICHOLINERGIC AGENTS

They are administered before administering ECT to minimize oral and respiratory secretions. The most commonly used Muscarinic Anticholinergic agent is Atrphine 0.3 to 0.6 mg administered IM or Subcutaneously 30 to 60 minutes before the anesthetic or 0.4 to 1.0 mg IV 2 or 3 minutes before anesthetic. An option to atrophine was Glycopyrrolate (Robinoul) 0.2 to 0.4 mg IM / IV / SC. Which is less likely to cross Blood Brain Barrier.

ANESTHESIA Administeration of ECT requires general anesthesia and oxygenation. Methohexital 0.75 to 1.0 mg /kg IV Bolus is commonly used. Other anesthetic agent is Thiopental ( Pentothal)

MUSCLE RELAXANTS
After the onset of the anesthetic effect, usually within a minute a muscle relaxant is administered, to minimize the risk of bone fractures and joints dislocations, resulting from motor activity during the seizure. Succinyl Choline is the choice of muscle relaxants which is administered in a dose of 0.5 to 1.0 mg/kg as an IV bolus.

ELECTORDES PLACEMENT
Bilateral Placement
Unilateral Placement

It yields a more rapid therapeutic response. It is the standard form of ECT and most commonly used. Electrodes are placed on each side one inch above the mid point of an imaginery line connecting the outer canthus of the eye and tragus of the ear.

Here the 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

ELECTRICAL STIMULUS
The electrical stimulus must be strong

enough to reach the seizure threshold. The electrical stimulus is given in cycles. Each cycles contains a positive and negative wave. Old machines use Sine wave: However the modern machines uses brief pulse waveform.

INDUCED SEIZURES
Plantar extension is the first sign of

the occurrence of seizure. Plantar extension lasts for 10 20 seconds which marks tonic phase. Rhythmic contraction (Clonic) follows the tonic phase, that decreases in frequency and finally disappears.

MONITORING SEIZURES

Observe the tonic clonic

phase movements or EEG readings to know the onset of seizure.

FAILURE TO INDUCE SEIZURE

Up to four attempts of seizure induction

can be tried in a single course of time. Onset of seizure activity is sometimes delayed as long as 20 to 40 seconds after administration of stimulus. If stimulus fails to induce seizure check the electrodes placement and increase the stimulus by 25 to 100%.

Failure to induce seizure

Change in anesthetic agent can be used to

minimize the seizure threshold. Additional procedure to induce seizure are Inducing hyperventilation Administering 500 2000 mg IV caffeine sodium benzoate 5 to 10 minutes before the administration of stimulus

NUMBER AND SPACING OF TREATMENT

ECT are usually administered two or

three times a week. 6 12 treatments for Major Depression. Mania treatment needs up to 20 seating's. Schizophrenia needs 15+. Catatonia and delirium requires 1 to 4 ECTs.

SIDE EFFECTS

Amnesia Confusion Memory impairment Palpitation Nausea and vomiting Anxiety & Restlessness Sweating Tongue Bite

Dizziness Dryness of mouth Headache Weakness & Fatigue Muscle pain Poor Concentration Incontinence

NURSES ROLE IN ECT

Pre ECT administration

During ECT administration

Post ECT administration