Electro Convulsive Therapy "ECT"

Introduction: Elctro convulsive therapy is the somat c treatment with the longest continuous history of use in psychiatry Initially the treatment was referred to electro shock therapy EST but later became known as electro convulsive therapy ECT. The wide use of convulsive therapy evolved from the repeated observation that when convulsion occurred, there was remission of symptoms in patient with depression and psychotic behaviors. HISTORY OF ECT: IN 1934 (LASZLO MEDUNA) Through intramuscularly injection of amphor in oil, deliberately induced generalized grand mal seizures with the intent to react psycoses (primarily schizophrenia), during the next decade, it switched to intravenously administer of penthy lenterazol(metrazol) and after that fluorthely(indoklon) apotent inhalant convulsant introduced. IN APRIL 1938 (CERLETTI&BINI): Electro convulsive therapy was introduced by two Italian psychiatrists in rome" cerletti&bini", they had doing research of ECT on "dogs" before application of this treatment to human being. IN THE LATE 1950: The clinical use of ECT greatly diminished with the introduction of psychotropic medications. THE 1980: Saw the beginning of a new era in ECT research as a growing awareness of the limitations, safety issues, and side effects of psychotropic medication became apparent. N.B: the convulsive therapy was firstly introduced in 1930 . In 1934 by meduna and. In April 1938 in Rome by two Italian clinicians cerletti&bini. DEFINITION: ECT is the induction of a grand mal seizure through the application of electrical current to the brain "fronto-temporal area" either unilateral or bilateral as type of treatment. OR: a method or form of treatment for psychiatric disorder applied by passing an electrical discharge through the one or both side of the brain fronto-temporal area to producing an artificial seizure which is important in cute the psychiatric symptoms. THE VOLTAGE: volts used 70-125 volts. DURATION: 0.7 to 1.5 seconds NUMBER OF TREATMENT: According to the condition or case and he response to therapy. Most patients require an average of 6 to 10 session but some may not reach a maximal response until after 20 to 25 treatments. Treatment are sessions usually administered 3 times per week.

 The course should not be exceed than 25 times. MECHANISM OF ACTION: Until now mechanism of action is unknown. A number of researchers have demonstrated that electrical stimulation results in significant increases in the circulating level of several neurotransmitters. These neurotransmitters include: serotonin, nor epinephrine, and dopamine, the same biogenic amines that are affected by antidepressant drugs. THEORIS OF ACTION: Theory hold that the patient perceives ECT as well deserve punishment and therefore feels less guilty. Another theory proposes that ECT has seen by clients as life threatening experience and they therefore mobilize all their bodily defenses to deal with this attack. It ha also been suggested that patients are able to release their inner aggressive impulses through the convulsions associated with the treatment. Other theory holds that the electric shock produces minimal brain damage, which destroys the specific area containing memories related to the events surrounding the development of the psychotic condition. Other theory view the brain as consisting of multiple electric circuits and sees mental illness as stemming from a malfunction of these electric circuits to they compensate by ECT. INDICATION OF ECT: 1- MAJOR DEPRESSION: For treatment of severe depression. Patients are experiencing psychotic symptoms and those with psychomotor retardation and neurovegative changes, such as disturbances in sleep, appetite and energy. Resistant cases of depressive disorder, which has not responded to adequate drug treatment. Patients with medical complicating medical conditions "e.g heart disease, narrow angel glaucoma" that could be worsened by psychotropic medications. It's used with certain precautions. Depressed patient with adverse reaction to psychotic medication "e.g neurleptic malignant syndrome, delirium, urinary retention, paralytic ileus" that contraindicate their use. 2-MANIA: ECT is also indicated for treatment of mania. Reason for referral should inculd one of the following: Ineffectiveness of pharmacological treatment strategies. Prior optimal respone to ECT. Severe psychopathology requiring prompt intervention e,g.. manic delirium." Severe agitation patient may be harmful for self and other" 3-SCHIZOPHERENIA: For acute catatonic schizophrenia. For schizo affective psychosis" schizophrenia with depression or mania.

CONTRAINDICATION: The only absolute contraindication of ECT is increased intracranial pressure( from brain tumor, recent cardiovascular accident or other cerebrovascular lesion). ECT temporarily elevates cerebrospinal fluids pressure and intracranial pressure so ECT is contraindicated. Recent myocardial infarction with unstable cardiac function. Also precludes ECT since arrhythmias may occur during the seizure and may precipitate another infraction when patient become stable ECT may be administered with caution when ECG, cardiac enzymes are stable. Severe hypertension: ECT is contraindicated to from more increase in hypertension, which may occur as result of stress that exhibited by patient pre, during and post of receiving ECT. Asthmatic patient may be treated but not during an acute attach due ti more difficulties in respiration thus during period of apnea and lead to fetal complication. Active bone disease e.g. severe osteoporosis is generally regarded as contraindication. Extra care is required with pregnant women with seizure may affect the fetus. Uncommon used in neurotic illness characterized by great anxiety because ECT increases the patient's apprehension and distress. PHASES OF THE CONVULSION OF ECT: 1- THE CRY PHASE: Sudden contraction of the respiratory and abdominal muscles forces air through the larynx producing a loud sound know as "epileptic cry" 2- THE TONIC PHASE: In this phase eyes are opened upward and pupils dilated, respiration are arrested temporarily, cyanosis at the same time muscle of the body contract and remain in its spasm from 10-15 seconds. 3- THE CLONIC PHASE: It can be noticed in the muscles of the face especially around the eyes and tremors of the hands and feet "peripheral system seizure". There is also saliva escaped from mouth and bleeding may be observed due to betting of tongue, lips or oral mucosa a there is also alternating contraction and relaxation of the voluntary muscles it take 30- 60 seconds 4- THE RECOVERY PHASE: Phase of consciousness regained" some patients sleep a few hours and some still confused and some other are mentally alert there are variation in mental alertness state most patient awake within 10 to 15 minutes of the treatment and are confused and disoriented m some pts with sleep 1-2 hrs per day. THE TECHNIQUE OF TREATMENT: 1. Preparation of the patient. 2. Preparation of equipment. 3. Management of convulsion. 4. After care.

1-PREPATATION OF THE PATIENT: A major aspect of the pretreatment stage is obtaining informed consent from the patient or family. The patient is usually informed on preceding night that he will receive that treatment n the following day and health teaching about ECT the nurse should reassure him that the procedure is painless and harmless nocturnal sedation is given to th patient. Fasting for at least 5-6 hrs as any procedure involving loss of consciousness as result of anesthesia with regurgitation and inhalation of gastric content during or immediately after procedure. Vital sings should be checked before treatment. The patient should be waiting in a place far from the treatment room to avoid increase in anxity level. Hair clips, pins, jewelers, false teeth is removed and labeled for safe keeping and tight clothing is loosened. Patient should be encouraged to empty his bladder and return immediately prior ECT. Hair and skin lotion detrimental to adequate stimulus electrodes contact should be avoided. Patient must undergo and complete: physical examination include, BL, Chemistries. CBC for shown any blood dyscrasias. Urine analysis for shown kidney function. X-ray for spine shows any injury or damage affected on the musculoskeletal system. Chest x-ray which may indicate presence of T.B that also preclude the treatment with ECT. EEG,ECG for shown any cardiac arrhythmias. 2- PREPARATION OF THE EQUIPMENT: This equipment is very important to found in the treatment room and its the nurse resonsbilities to see not only that it is there but also it is in perfect working order: Electro convulsive therapy machine. Electrodes, which placed over each temporal area. Electrode contact solution as jell. Cylinders the apparatus for inflating the lung such as oxygen mask or nasal tube. Syringes and needles. Tourniquets, swabs, solution and kidney basin or container. Clastoplasts for applying pressure dressing to the site of vein puncture. Mouth gag it must be broad to prevent damage that occur in lips, teeth, tongue, jaws also to prevent the tongue from falling. Sucker with number of metal hand pieces which can be replaced as used. Pharyngeal airway"geudal" laryngoscope, endotracheal tube and the appropriate connection. I.V anesthetic agen "sodium methohexital" "bevital sodium". Muscle relaxant drugs"succinglocholine""anectine" mixed immediately prior to use this muscle relaxant is give to prevent violent muscle contraction, muscle relaxant is given after anesthetic agent as it produces a state of paralysis, which may cause the patient to be very anxious, if it is given before anesthesia.

 Atropine 0.6-1 mg IM or IV. The beds or trolleys or stretcher with covered pillows and mattress with mackintosh and appropriate covering for the patient after treatment has been given.

THE PATIENT CHART: Should accompany him t the treatment room for recording everything in details and the medical staff can take any information about pt's condition before attending to treatment room. PATIENT AT THE TREATMENT ROOM: The patient lies in a supine position on stretcher with small pillow under the head of pt. PRE-MEDICATION: I.M atropine sulfate 0.6-1mg for 30 minutes before treatment or I.V anesthesia it reduces cardiac arrhythmia that may occur during and reduce the bronchial spasm and tracheobronchial secretion" dry secretion" that essential to prevent the regurgitation and suffocation. The anesthesiologist administers a short acting barbiturate such as sodium methohexital"bevital sodium" i.v to induce anesthesia" anesthetic agent" Followed immediately by an i.v injection of the muscle relaxant as succinylcholine. As patient become paralyzed due to muscle relaxant an oxygen is a administer from 95 to 100 percent oxygen to allowing the lung to be inflated for about 30-45 second. N.B: ensures the the patient is not receive any drugs such as maois, it interfere with anesthetic. 3- Management of convulsion: Clean the skin of temporal area at the head is cleaned and moistened electrodes are applied "jell" if dry electrodes it may be lead to burn and of excessive moisture causes shorting and prevent a seizure response. Apply the electrode over each temporal area of the scalp bilaterally or no dominant temporal scalp unilaterally. Mouth gag is inserted between teeth. Then the shock is given, the nurse should support the lower jaw during the electric shock as a violent clenching of the jaw through to avoid misplacement which leading to different injuries. Firm support and apply pressure on the main joints of the body such as shoulder, elbow, hip, and knee joint to protect the patient from several hazards which may occur during grand mal seizure during this period the patient not breathing adequately so o2 is given prior the procedure to prevent cyanosis. After the fit subsided the nurse is administer i2 until patient breathing become spontaneous without help or assistance. As the patient still unconscious, he should kept patient in lateral position and nursed in semi porn position and kept patient under closed observation. 4- AFTER CARE: A closed observation is given to the patient for : Airway, skin color, cyanosis, any obstruction or inadequate respiration should be reported airway should be clear by suction and in emergency mouth to mouth breathing is provided Checking vital signs frequently until stability

 As the patient walking from the first time he may return to dozing in the semi-prone position or he may attempt patient to get off the bed. The patient should remain in his bed, as he hasn't an ability to stand or walk. Disorientation and disturbance of behavior are temporary and usually don't require treatment the role of nurse there is to reorient the patient with time, place, person. Confusion for a varying period after treatment is rule, rarely a patient may become quite difficult to manage. Headache is commont complaint during the recovery period and may be treated by aspirin unless the patient suffers from disorder, which contraindicated its use as peptic ulcer. An outpatient should be supported with a friend or relative to lead he to his some and drivin a car is contraindicated for at least 24 hrs to avoid risk due to drowsness following the treatment with ECT. SIDE EFFECTS: The most common side effect of ECT are: Headache Confusion Temporary memory loss. This side effect lasts for first few hours after treatment COMPLICATIONS OR RISKS: Injuries of the tongue , teeth or lips due to misplacement of mouth gag or air way tube. Brain damage: Which refer to inadequate oxygenation. Permanent memory loss: is rare occurs Confusion: as result of impairment in a cognitive function(orientation, memory, intellect, attention and concentration), this is commonest in the elderly patients must be immediately reported as it is the main cause of the psychiatrist to discontinue the treatment Fracture: its due to an error in the administration of the relaxant it is not given into the vein, if the patient complain from back or lower limb pain, it should be investigate for presence of fracture or dislocation. Death or mortality rate: may occur but its rare between 0.01 and 0.04 percent. It may occur due to complication of anesthesia(o2 administer prior the treatment) and cardiac complication. ETHICAL CONSIDERATION: Physicians should prescribe ECT only for valid clinical reasons and should use the minimum number of treatment necessary for the therapeutic effect, there by total number of session should not exceed than 25 times. Should not allow for the patient that will receive ECT to see or hear another who treats by ECT. You have never put in our mind that the treatment of ECT is away for punishment.