HOW TO GIVE ECT
A series of one or more spaced epileptic fits is of therapeutic benefit to some patients. A fit is most conveniently induced by a controlled electric shock.
This should always be done under muscle relaxant and anaesthetic to prevent the ill-effects of sudden trauma and raised blood pressure.
This sheet does not consider any ethical or legal issues but summarises the principal points of good technical practice.
PREPARING THE PATIENT
1. Explain the procedure.
2. Check physical health and the state of teeth, which may require dentist.
3. Myocardial infarct within 30 weeks, or cerebral haemorrhage within 15 weeks may contra-indicate treatment.
4. On the morning of treatment no food or drink (diabetics may need glucose and insulin 4 hours before treatment and should be taken first).
5. Postpone treatment if patient has cold or other acute respiratory infection.
6. Sedate anxious patient beforehand.
7. Patient empties bladder and removes false teeth and hair grips before treatment. Take off shoes, loosen clothing.
THE PSYCHIATRIST IS RESPONSIBLE FOR
1. Telling the anaesthetist and nurses beforehand about any medical or behavioural problems and patient’s current drugs, and reading out the doses and results of previous treatments before each patient enters treatment room.
2. Speaking words of encouragement and support to the patient in the treatment room, and Keeping a calm, humane, unhurried, caring atmosphere throughout treatment. Remember patients can hear and misinterpret casual remarks between staff.
3. Checking physical preparedness of patient; and presence of papers–approval for ECT, treatment sheet with doses, etc. in treatment room.
4. Keeping written record of each dose of electricity, relaxant and anaesthetic, and the presence or absence of a FIT each time.
5. GIVING THE TREATMENT
6. Observe immediate recovery and transfer to recovery
Check ECT apparatus switched on and working.
Make good contact between electrodes and head.
Press electrode firmly in place: if “Ectron” bilateral headset is used keep handle over bridge of nose.
Press stimulus switch, and keep electrodes ON skin until current stops (shown by dial, light or bleep on machine: 2-5 seconds)
If there is no fit many people set machine to maximum and then give a second shock, but if there is still no fit they then give up for that day.
In unilateral ECT the stimulus should be given on the side of the head which is non-dominant for language. This is the RIGHT side in nearly all R-handed and in 70% of L-handed people.
Ask the patient beforehand which is his preferred hand, foot, eye; give the first ECT to the RIGHT side and observe the effect. Patients are usually less confused during the immediate recovery period after ECT to the non-dominant side than after dominant or bilateral ECT.
Observe carefully at this time; if confusion, and especially with dysphasia, lasts for more than 5 minutes (time it after consciousness is regained, give the next ECT to the other side of the head and time it again. Then use the side producing shorter confusion. If there is marked confusion with both applications you are probably using too much electricity and should reduce the sumulus.
Point A is 4 cm above the midpoint between earhole and angle of orbit. Point B is 6 cm from A, and above the earhole. (other positions may be acceptable. make sure it you want to use one).
Point A on each side as for unilateral point A: if the two electrodes are mounted on a single headset hold it vertical to the supine patient.
For simplicity only one unilateral electrode placement is given, but others may be acceptable.
Report difficulties to the Consultant in charge and Nursing Officer.
To make good electrical contact always soak electrode pads well in the electrolyte solution, bur be careful no excess solution runs down over the patient’s skin. Clean the skin (and hair) with detergent where you will place electrodes.
Remove hair pins and part the hair where necessary. Failure here may result in failure to produce a fit; or a superficial skin burn because of undue concentration of current in one pathway. Press electrodes firmly.
“SUCCESSFUL TREATMENT DEPENDS ON GIVING A BILATERALLY EVIDENT FIt
This will be shown at least by a rhythmical twitching of the small muscles under the skin around both eyes. by rhythmic twitching of both thumbs and both big toes. This twitching lasts for a few seconds up to ½-minute or more and comes on with a delay of up to 10 seconds after delivery of the electric shock. It is not the same as the sudden muscular contractions produced acutely by the shock as it is given. These contractions mean nothing. Only the delayed twitching, shown by both sides of the body, indicates a successful treatment, even in unilateral ECT.
Diagrams by O. McGreror
ROYAL COLLEGE OF PSYCHIATRISTS
17 Belgrave Square
London SWIX 8PG
Further copies of this poster available on request.