Professional Documents
Culture Documents
Ag
0
Reference
V
Voltmeter
Fig. 1.PCO
2
Electrode
(Dissolve
d Entrance
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Base Excess or Base Deficit
Whenever there is an accumulation of metabolically-produced acids, the body
attempts to neutralize those acids to maintain a constant acid-base balance.
This neutralizing is achieved by using up various "buffering" compounds in the blood
stream, to bind the acids, disallowing them from contributing to more acidity.
About half of these buffering compounds come from HCO3, and the other half from
plasma and red blood cell proteins and phosphates.
The words "base deficit" and "base excess" are equivalent and are generally used
interchangeably. The only difference is that base deficit is expressed as a positive
number and base excess is expressed as a negative number.
A "Base Deficit" of 10 means that 10 mEqu/L of buffer has been used up to neutralize
metabolic acids (like lactic acid). Another way to say the same thing would be the
"Base Excess is minus 10."
Exit
For blood
Or calibrating
gas
Semipermeable
membrane
Glass
O
2
Sample Chamber
AgCl Ag
0
Reference
V
Voltmeter
Fig. 1.PO
2
Electrode
(Dissolve
d Entrance
Cathode
Anode
O
2
e
-
e
-
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More Negative Values of Base Excess may Indicate:
- Lactic Acidosis
- Ketoacidosis
- Ingestion of acids
- Cardiopulmonary collapse
- Shock
More Positive Values of Base Excess may Indicate:
- Loss of buffer base
- Hemorrhage
- Diarrhea
- Ingestion of alkali
4.13. RESTING POTENTIALS AND ACTION POTENTIALS
When a cell membrane moves molecules or ions uphill against a concentration gradient, then the
process is known as active transport. The transport of the substances through the cell membrane
occurs by diffusion is called passive transport. The diffusion and drift processes give rise to
membrane potential.
The interface of metallic ions in solution (or) with their associated metal results in an electrode
potential. The voltage developed at an electrode- electrolyte interface is designated as half- cell
potential or electrode potential. In the case of a metal- solution interface electrode potential
results from the difference in the rates between two opposing processes. They are passage of ions
from the metal into the solution, combination of metallic ions in solution with electrons in the
metal to form atoms of the metal.
Various ions seek balance between the inside and outside of the cell by diffusion and drift
process give rise to membrane potential. The membrane potential caused by the different
concentration of ions is called the resting potential of the cell. Resting potential is defined as the
electrical potential of an excitable cell relative to its surroundings when not stimulated or
involved in passage of an impulse. It ranges from -60mV to -100mV
The nerve and muscle cells permit the entry of potassium and chloride ions it blocks the entry of
sodium ions. The permeability of sodium ions is about 2 x 10-8 cm/s and for potassium and
chloride ions is 4 x 10-6 cm/s
Action potential is defined as the change in electrical potential associated with the passage of an
impulse along the membrane of a cell.
The various ions seek a balance between the inside and outside of the cell by diffusion and drift.
When the cell is in resting state, then it is said to be polarized. The process of changing from the
resting potential state to the action potential state is called depolarization.
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2 2
1 1
ln
f C
f C
nF
RT
E =
When the cell fires however, the outside of the cell becomes momentarily negative with respect
to the interior. A short time later, the cell regains the normal state in which the inside is again
negative with respect to outside. The discharging and recharging of the cell is known as
depolarization and repolarization.
Regardless of the method of excitation of cells or the intensity of the stimulus, this is assumed to
greater than the threshold of stimulus. The action potential is always- the same for any given cell.
This is known as all- or nothing law.
Absolute refractory period is the time duration of the cell non response to further stimuli. It is
about 1 millisecond in nerve cell. Following the absolute refractory period there is a brief period
of time during which another action potential can be triggered but a much stronger stimulation is
required. This period is called relative refractory period.
The rate at which an action potential moves down a fiber of a nerve cell or is propagated from
cell to cell is called the propagation rate or conduction velocity. The conduction velocity varies
in nerves depending on the type and diameter of the fiber and is from 20 n/s to 140 m/s. But in
heart muscle, it is very slower ranging from 0.2 to 0.4 m/s.
Due to the difference in permeability the concentration of sodium ions inside the cell becomes
much lower than the outside the cell. Since the sodium ions are positive, the outside of the cell is
more positive than inside. The concentration of potassium and chloride ions is negative on the
inside and positive on the outside.
An equation relating the potential across the membrane and the two concentrations of the ion is
called Nernst equation.
Where,
R gas constant(8.315 x 10
7
ergs/mole/degree Kelvin)
T absolute Temperature, degrees Kelvin
n valence of the ion (the number of electrons added or removed to ionize the atom)
F Faraday constant (96,500 coulombs)
C
1,
C
2
two concentrations of the ion on the two sides of the membrane
f
1
, f
2
respective activity coefficients of the ion on the two sides of the membrane
The approximate value of the resting potential for living cell is 70mV. The resting potential
ranges from -60 to -100nV.
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The characteristics of resting potential are .
- The value of the resting potential is maintained as a constant until some kind of
disturbance occurs.
- It is strongly depending on the temperature.
- Since the permabilities of the different cell types vary, the corresponding resting
potentials vary.
Bio electric potential related to
Heart ElectroCardioGram (ECG)
Brain ElectroEncephaloGram (EEG)
Muscle ElectroMyoGram (EMG)
Eye (Retina) ElectroRetinoGram (ERG)
Eye (Cornea - Retina) ElectroOculoGram (EOG)
Bioelectric potential Function Peak
amplitude
Frequency
response
Observation
ElectroCardioGram
(ECG)
Records
electrical
activity of heart
0.1 to 4mV 0.05 to
120 Hz
Used to measure
heart rate,
arrhythmia and
abnormalities
ElectroEncephaloGram
(EEG)
Records
electrical
activity of
brain
2 to 200V 0.1 to 100
Hz
Used to analysis
evoked potential,
certain patterns,
frequency
response
ElectroMyoGram
(EMG)
Records
muscle
potential
50V to
1mV
5 to 2000
Hz
Used as indicator
of muscle action
for measuring
fatigue
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4.14. Pacemaker
Inroduction
Pacemaker is an electrical pulse generator for starting /maintaining the normal heart beat.
The output of the pacemaker is either externally to the chest or internally to the heart
muscle. In the case of cardiac stand still, the use of the pacemaker is temporary just
long enough to start a normal heart rhythm. In the cases requiring long term pacing, the
pacemaker is surgically implanted in the body and its electrodes are in direct contact with
the heart. The contraction of heart (cardiac) muscle in all animals with hearts is initiated
by electrical impulses. The rate at which these impulses fire controls the heart rate. The
cells that create these rhythmical impulses are called pacemaker cells, and they directly
control the heart rate. The normal heart rate is 60-100 beats per minute.
A higher rate than this ( above 100 beats per minute) is called Tachycardia. slower
rate(Below 60 beats per minute) than this is called Bradycardia .
IMPLANTING THE PACEMAKER
Definition of Pacemaker
A small battery powered device, implanted into a patient Paces the heart when normal
rhythm is slow, when there is a heart block not allowing the ventricles to contract when the SA
node fires, or any arrhythmia causing a slow rate.
Determining Pacemaker Types
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In humans, and occasionally in other animals, a mechanical device called an artificial
pacemaker (or simply "pacemaker") may be used after damage to the body's intrinsic conduction
system to produce these impulses synthetically. The pacemaker is located in the wall of the right
atrium.
Cardiac Pacemaker
The sinoatrial node (SA node) is a group of cells positioned on the wall of the right atrium,
near the entrance of the superior venacava. These cells are modified cardiomyocyte. They
possess rudimentary contractile filaments, but contract relatively weakly.
Primary Pacemaker
Cells in the SA node spontaneously depolarize, resulting in contraction, approximately 100 times
per minute. This native rate is constantly modified by the activity of sympathetic
and parasympathetic nerve fibers, so that the average resting cardiac rate in adult humans is
about 70 beats per minute. Because the sinoatrial node is responsible for the rest of the heart's
electrical activity, it is sometimes called the primary pacemaker.
Secondary Pacemaker
If the SA node does not function, a group of cells further down the heart will become the ectopic
pacemaker of the heart. These cells form the atrioventricular node(or AV node), which is an area
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between the left atrium and the right ventricle, within the atrial septum. The cells of the AV node
normally discharge at about 40-60 beats per minute, and are called the secondary pacemaker.
Pacemaker Potential
The pacemaker potential (also called the pacemaker current) is the slow, positive increase in
voltage across the cells membrane (the membrane potential) that occurs between the end of
one action potential and the beginning of the next action potential. This increase in membrane
potential is what causes the cell membrane, which typically maintains a resting membrane
potential of -70 mV, to reach the threshold potential and consequently fire the next action
potential; thus, the pacemaker potential is what drives the self-generated rhythmic firing
(automaticity) of pacemaker cells, and the rate of change (i.e., the slope) of the pacemaker
potential is what determines the timing of the next action potential and thus the intrinsic firing
rate of the cell.
In a healthy sinoatrial node (SAN, a complex tissue within the right atrium containing pacemaker
cells that normally determine the intrinsic firing rate for the entire heart), the pacemaker potential
is the main determinant of the heart rate. Because the pacemaker potential represents the non-
contracting time between heart beats ( diastole), it is also called the diastolic depolarization. The
amount of net inward current required to move the cell membrane potential during the
pacemaker phase is extremely small, in the order of few pAs, but this net flux arises from time to
time changing contribution of several currents that flow with different voltage and time
dependence
Artificial Cardiac Pacemaker
A pacemaker (or artificial pacemaker, so as not to be confused with the heart's natural
pacemaker) is a medical device that uses electrical impulses, delivered by electrodes contracting
the heart muscles, to regulate the beating of the heart. The primary purpose of a pacemaker is to
maintain an adequate heart rate, either because the heart's natural pacemaker is not fast enough,
or there is a block in the heart electrical conduction system. Modern pacemakers are externally
programmable and allow the cardiologist to select the optimum pacing modes for individual
patients. Some combine a pacemaker and defibrillator in a single implantable device. Others
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have multiple electrodes stimulating differing positions within the heart to improve
synchronization of the lower chambers (ventricles) of the heart.
Pacemaker Pulses
These Pulses should have the pulse to space ratio 1:10000.
It should be negatively going pulses to avoid the ionization of the muscles.
The pulse voltage is made variable to allow adjustments in the energy delivered by the
pacemaker to the heart during each pulse.
Methods of stimulation
External stimulation
Internal stimulation
External stimulation is employed to restart the normal rhythm of the heart in the case of cardiac
standstill. Internal stimulation is employed in cases requiring long term pacing because of
permanent damage that prevents normal self triggering of the heart.
External Stimulation
It is employed to restart the normal rhythm of the heart in the case of cardiac stand still.
Stand still can occur during openheart surgery or whenever there is a sudden physical shock or
accident.
Internal Stimulation
Internal stimulation is employed in cases requiring long term pacing because of permanent
damage that prevents normal self triggering of the heart.
Comparision between external pacemaker and internal pacemaker.
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External pacemaker Internal pacemaker
It does not necessitate open heart surgery The pacemaker is surgically implanted
beneath
The skin near the chest or abdomen with its
output leads are connected directly to he
heart muscle
It requires open chest minor surgery to
place the circuit
These are used for temporary heart
irregularities. There is no safety or
pacemaker.
These are used for permanent heart
damages. There is cent percent safety for
circuit from external disturbances
Electrodes for Stimulation
Bipolar and unipolar electrodes are used.
In the bipolar electrode, there are stimulating electrode and contact electrode which
serves as a return path for current to the pacemaker.
In the unipolar electrode, there is only stimulating electrode.
The return path for current to the pacemaker is made through the body fluids.
Modes of operation of pacemaker
Ventricular asynchronous pacemaker ( Fixed rate pacemaker)
Ventricular synchronous pacemaker
Ventricular inhibited pacemaker ( Demand pacemaker)
Atrial synchronous pacemaker.
Atrial sequential ventricular inhibited pacemaker.
Ventricular asynchronous pacemaker
It can be used in atrium or ventricle. It has simplest mechanism and longest battery life.
This pacemaker is suitable for patients with either a stable, total AV block, a slow atrial rate or
atrial arrhythmia. This produces a stimulus at a fixed rate irrespective of the behavior of heart
rhythm. There may be competition between the natural heart beats and pacemaker beats.It is
possible that such an event can be dangerous because if the pacemaker impulse reaches the heart
during a certain vulnerable period, the ventricular fibrillation may occur.
Advantages and disadvantages of ventricular synchronous pacemaker.
Advantages:
- To arrest the ventricular fibrillation, this circuit can be used.
- If the R wave occurs with its normal value in amplitude and frequency, then it would not
work. Therefore the power consumption is reduced, and there is no chance of getting side
effects due to competition between natural and artificial pacemaker pulses.
Disadvantages:
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- Atrial and ventricular are not synchronized.
- I the olden type when the pacemaker is attached with the patients, the circuit is more
sensitive to external electromagnetic interferences such as electric shavers, microwave
ovens, ignition systems.
Ventricular synchronous Pacemaker
Patients with only short periods of AV block or bundle block can be supplied with a ventricular
synchronized pacemaker.This type of pacemaker does not compete with normal heart activity
Working of Ventricular Synchronous Pacemaker
Using the sensing electrode, the heart rate is detected and is given to the timing circuit in the
pacemaker. If the detected heart rate is below a certain minimum level, the fixed rate pacemaker
is turned on to pace the heart. The lead used to detect the R wave is now used to stimulate the
heart. If the natural contraction occurs, the asynchronous pacers timing circuit is reset so that it
will time its next pulse to detect the heart beat
Advantages of ventricular synchronous pacemaker:
- To arrest the ventricular fibrillation, this circuit can be used.
- If the R wave occurs with its normal value in amplitude and frequency, then it would not
work. Therefore the power consumption is reduced, and there is no chance of getting side
effects due to competition between natural and artificial pacemaker pulses.
Disadvantages of ventricular synchronous pacemaker:
- Atrial and ventricular are not synchronized.
- I the olden type when the pacemaker is attached with the patients, the circuit is more
sensitive to external electromagnetic interferences such as electric shavers, microwave
ovens, ignition systems.
Ventricular inhibited Pacemaker (Demand Pacemaker)
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.
The R- Wave inhibited pacemaker also allows the heart to pace at its normal rhythm when it is
able to . However if the R- wave is missing for a preset period of time, the pacer will supply the
stimulus. Therefore if the heart rate is below a predetermined minimum, pacemaker will turn on
and provide the heart a stimulus. For this reason it is called demand pacemaker.
The sensing electrode pickup R wave. The refractory circuit provides a period of time following
an output pulse or a signals. The sensing circuit detects the R wave and resets the oscillator. The
reversion circuit allows the amplifier to detect the R- wave in low level signal to noise ratio. In
the absence of R wave, it allows the oscillator in the timing circuit to deliver pulses at its preset
rate. The timing circuit consists of an RC network, a reference voltage source and a comparator
which determines the basic pulse rate of the pulse generator. The output of the timing circuit is
fed into pulse delivered to the heart. Then the output of the pulse width circuit is fed into the rate
limiting circuit which limits the racing rate to a maximum of 120 pulses per minute.
Atrial synchronous pacemaker
This type of pacing is used for young patients with a mostly stable block. Atrial pacing as a
temporary pacing is used in stress testing and coronary artery diseases. It is used to terminate
atrial flutter and in the evaluation of various conduction mechanisms. The atrial activity is picked
up by a sensing electrode placed in a tissue close to the dorsal wall of the atrium. The detected P
wave is amplified and a delay of 0.12 second is provided by the AV delay circuit. This is
necessary corresponding to the actual delay in conducting the P wave to the AV node in the
heart. The signal is then used to trigger the resetable multivibrator and the output of the
multivibrator is given to the amplifier which produces the desired stimulus to be applied to the
heart
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Heart
5.1.Electrical conduction system of the heart
The EKG complex.
P=P wave,
PR=PR interval,
QRS=QRS complex,
QT=QT interval,
ST=ST segment,
T=T wave
The normal electrical conduction in the heart allows the impulse that is generated by the
Sinoatrial node (SA node) of the Heart to be propagated to (and stimulate) the
myocardium (muscle of the heart).
After myocardium is stimulated, it contracts.
It is the ordered stimulation of the myocardium that allows efficient contraction of the
heart, thereby allowing blood to be pumped throughout the body.
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5.2.SA node:
5.2.1P wave
Under normal conditions, electrical activity is spontaneously generated by the SA node,
the physiological pacemaker.
This electrical impulse is propagated throughout the right and left atria, stimulating the
myocardium of the atria to contract.
The conduction of the electrical impulse throughout the atria is seen on the ECG as the P
wave.
5.2.2.INTERNODAL TRACTS,
As the electrical activity is spreading throughout the atria,
it travels via specialized pathways, known as internodal tracts,
from the SA node to the AVnode.
The P wave is the electrical signature of the current that causes atrial depolarization.
Both the left and right atria contract simultaneously. Its relationship to QRS complexes
determines the presence of a heart block.
Irregular or absent P waves may indicate arrhythmia.
The shape of the P waves may indicate atrial problems.
5.2.3.AV node/Bundles: PR interval
The AV node functions as a critical delay in the conduction system.
Without this delay, the atria and ventricles would contract at the same time, and blood
wouldn't flow effectively from the atria to the ventricles.
The delay in the AV node forms much of the PR segment on the ECG.
And part of atrial repolization be represented by PR segment.
5.3.Bundle of His
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The distal portion of the AV node is known as the Bundle of His .
The Bundle of His splits into two branches in the interventricular septum, the left bundle
branch and the right bundle branch.
The left bundle branch activates the left ventricle, while the right bundle branch activates
the right ventricle.
The left bundle branch is short, splitting into the left anterior fascicle and the left
posterior fascicle.
The left posterior fascicle is relatively short and broad, with dual blood supply, making it
particularly resistant to ischemic damage.
5.4.Purkinje fibers/ventricular myocardium: QRS complex
The two bundle branches taper out to produce numerous Purkinjie fibers,
which stimulate individual groups of myocardial cells to contract.
The spread of electrical activity through the ventricular myocardium produces the QRS
Complex on the ECG.
The QRS complex corresponds to the current that causes contraction of the left and right
ventricles,
which is much more forceful than that of the atria and involves more muscle mass,
thus resulting in a greater ECG deflection.
The Q wave, when present,
represents the small horizontal (left to right) current as the action potential travels
through the interventricular septum.
Very wide and deep Q waves do not have a septal origin, but indicate myocardial
infraction that involves the full depth of the myocardium and has left a scar.
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Abnormalities in the QRS complex
Bundle branch block (when wide), ventricular origin of tachycardia, ventricular
hyperthrophy or other ventricular abnormalities.
The complexes are often small in pericarditis or pericardial effusion
5.5.R and S wave
The R and S waves indicate the spread of the action potential along the ventricular
myocardium itself.
5.6.ST Segment
The ST segment connects the QRS complex and the T wave.
ST segment elevation or ST segment depression) may indicate coronary ischemia or
myocardial infraction.
5.7.Ventricular repolarization: T wave
The last event of the cycle is the repolarization of the Ventricles.
In most leads, the T wave is positive.
An impulse (action potential) that originates from the SA node at a rate of 60 - 100
beats/minute (bpm) is known as normal sinus rhythm.
If SA nodal impulses occur at a rate less than 60 bpm, the heart rhythm is known as sinus
bradycardia.
If SA nodal impulse occur at a rate exceeding 100 bpm, the consequent rapid heart rate is
sinus tachycardia.
These conditions are not necessarily bad symptoms, however.
Trained athletes, for example, usually show heart rates slower than 60bpm when not
exercising
5.8.ECG waveforms Lead III
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5.9.USES OF ECG :
It is the gold standard for the evaluation of cardiac arrhythmias .
The 12 lead ECG stands at the center of risk stratification for patients with suspected
acute myocardial infraction .
It can be useful for detecting electrolyte disturbances (e.g. potassium or calcium).
Allows the detection of conduction abnormalities (e.g. right and left bundle branch
block).
As a screening tool for ischemic heart disease during an cardiac stress test.
Can suggest non-cardiac disease (e.g. pulmonary embolism or hypothermia).
5.10.Normal ECG
The baseline voltage of the electrocardiogram is known as the isoelectric line.
A typical ECG tracing of a normal heartbeat consists of a P wave, a QRS complex and a
T wave.
A small U wave is normally visible in 50 to 75% of ECGs.
5.10.1.ECG lead configurations
Surface electrodes are used with jelly as electrolyte between skin and electrodes.
The potentials generated in the heart are conducted to the body surface.
The potential distribution changes in a regular and complex manner during each cardiac
cycle.
To record electrocardiograms standard electrode positions must be selected.
four types of electrode systems are there. They are:
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Bipolar limb leads (or) standard leads.
Augumented unipolar limb leads.
Chest leads (or) precordial leads.
Frank lead system (or) corrected orthogonal leads.
The baseline voltage of the electrocardiogram is known as the isoelectric line.
A typical ECG tracing of a normal heartbeat consists of a P wave, a QRS complex and a
T wave.
A small U wave is normally visible in 50 to 75% of ECGs.
5.10.2.Bipolar limb leads
In standard leads the potentials are tapped from four locations of our body.
They are
Right arm
Left arm
Right leg
Left leg.
Usually right leg electrode is acting as ground reference electrode.
Electrode from
LA
Electrode from RA
+
- Ground electrode RL
Output V
I
Gives voltage VI, the voltage drop from left
arm(LA) to right arm (RA).
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Einthoven triangle.
Lead I
Lead III
Lead II
Right arm Left arm
-
-
+
-
Left leg
+
+
Cardiac vector
The closed path RA to LA to LL and back to RA is called Einthoven triangle.
The ECG is measured from any one of the three limb leads is a time variant single
dimensional component of that vector.
According to kirchoffs voltage law ,
the R wave amplitude of lead II is equal to the sum of the R wave amplitudes of leads I
and leadIII
VII = VI + VIII
5.10.3.Augmented unipolar limb leads
Unipolar limb lead system is introduced by Wilson.
Here ECG is recorded between a single exploratory electrode and the central
terminal.The central terminal has a potential corresponding to the center of the body.Two
equal and large resistors are connected to a pair of limb electrodes and the center of this
resistive network acts as central terminal. The remaining limb electrode acts as the
exploratory electrode. By means of augmented ECG lead connections, a small increase in
the ECG voltage can be realized.
The augmented lead connections are
Augmented voltage right arm (aVR)
Augmented voltage left arm (aVL)
Augmented voltage foot (aVF)
5.10.4.Unipolar chest leads
In case of unipolar chest leads, the exploratory electrode is obtained from one of the chest
electrodes.The chest electrodes are placed are placed on the six different points on the
chest closed to the heart.
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V1 : fourth intercostal space at right sternal Margin.
V2: fourth intercostal space at left sternal
Margin.
V3: midway between V2 and V4.
V4: fifth intercostal space at mid-clavicular line
V5: same level as V4 on anaterior axillary line
V6: same level as V4. On mid-axillary line.
Color codes for ECG leads
The ECG potentials are measured with color coded leads according to the convention:
White right arm
Black left arm.
Green right leg.
Red left leg.
Brown - chest
5.10.4.Frank lead system
The corrected orthogonal leads system (or ) frank lead system is used in vector
cardiography. Here we can get informations from above said 12 leads.
5.11.ANALYSIS OF ECG SIGNALS
If PQ segment has prolonged condition I.e. extended f normal condition means
Result :First degree AV block
If QRS complex is widened I.e. QRS interval extended from the normal condition means
Result : Bundle block.
If ST segment is elevated means Result : Myocardial infraction.
If train of pulses occurs instead of PQRST waves means Result : Ventricular fibrillation
which may lead to death if it is not properly corrected by defibrillator.
5.12.DIFFERENT TYPES OF HEART BLOCK
I degree AV block: due to prolonged conduction time.
II degree AV block : Due to conduction of few pulses instead of all from atrium
III degree AV block: Due to asynchronous action of atrium and ventricle
Adams-stokes attack: Due to sudden attack of total block.
Bundle block: due to improper conduction of the stimulus to the ventricle.
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Atrial fibrillation: Due to fast beating rate (300-500 beats/minute) of the atrium. Here
ventricles beat very slowly.s
Ventricular fibrillation: due to fast beating rate of the ventricles. No pumping of the
blood to different parts of the body.
5.13.Heart Transplantation
5.13.1.allo graft
Heart transplantation or cardiac transplantation, is a surgical transplant procedure
performed on patients with end-stage heart failure or severe coronary artery disease.
The most common procedure is to take a working heart from a recently deceased organ
donor (allo graft) and implant it into the patient.
The patient's own heart may either be removed (orthotopic procedure) or, less commonly,
left in to support the donor heart (heterotopic procedure).
5.13.2.xenograft
It is also possible to take a heart from another species (xenograft), or implant a man-
made artificial one,
although the success of these two procedures has been less successful in comparison to
the far more commonly performed allograft
5.13.3.Indications
In order for a patient to be recommended for a heart transplant they will generally have
advanced, irreversible heart failure with a severely limited life expectancy.
Other possible treatments, including medication, for their condition should have been
considered or attempted prior to recommendation.
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5.14.Causes of heart failure
Cardiomyopathy
Congential heart disease
Coronary artery disease
Heart valve disease
Life-threatening arrhythmias.
5.15.Patient cable and defibrillator protection circuit:
The patient cable connects the different leads from limbs and chest to the defibrillator
protection circuit.. it consists of buffer amplifiers and over voltage protection circuit. The leads
are connected with the buffer amplifiers such that one buffer amplifier for each patient lead. By
this meanss the input impedance is increased and the effects arising from the variations in the
electrode impedance are reduced.further the over voltage protection circuit is necessary to avoid
any damage to the bioamplifiers in the recorder. The over voltage of the order of 1000V may
occur when the electrocardiograph is used during surgery in conjunction with radio frequency
diathermy units for cutting and coagulation or during the treatment pf ventricular fibrillation
using defibrillators. This over voltage protection circuit consists of a network kof resistors and
neon lamps which fire when a pulse from a defibrillator is present. During firing of the neon
lamp, there is no input to the preamplifier of the recorder.
5.15.1.LEAD SELECTOR SWITCH:
After the defibrillator protection circuit, there is lead selector switch which is used to feed
the input voltage from the appropriate electrode to the preamplifier.
5.15.2.CALIBRATOR:
A push button allows the insertion of a standardization voltage of 1mV to the
preamplifier. This enables the technician to observe the output on the display unit and adjust the
scale so that a known deflection corresponds to a 1mV input signal. Changing the setting of the
lead selector switch introduces an artifact on the recorded trace. But by means of a special
contact on the lead selector switch the amplifier is momentarily turned off during the change of
setting of the lead selector switch and after the passage of the artifact the amplifier is turned on.
From the lead selector swithc the ECG signal goes to bio-amplifier.
5.15.3.BIO-AMPLIFIER:
The bio-amplifier consists of a preamplifier and power amplifier. The sensitivity or the
gain of the amplifier can be varied. Folllowed by the preamplifier, there is a power amplifier
which is used to drive the recorder. Pen motors in the recorder requires suffficient electrical
power to activate the recording or display. therefore power amplifiers are required with high
power gain. Generally transistor circuits are favourable because a relatively large surface area is
necessary to dissipate the heat genertd in the circuit due to passage of high current.
Power amplifier circuit used to drive ECG chart recorder stylus. It is push pull type.
Furtehr it is provided with crossover distortion compenstation and offset control. It consists of
two silicon power transistors such that the emitters of the transistors are joined together and
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connected with a load resistor R
L
.when V
B
is sufficiently positive, transistor Q1 is forward
biased and conducts while Q2 is reverse biased and remains off.
Output power P
OUT
=V
2
OUT
/ R
L
.
To avoid the crossover distortion in a pushpull amplifier, an ideal noninverting amplifier is
inserted at the input. Since the input impedance of the noninverting amplifier approaches
infinity, the power gain also approaches infinity. The crossover distortion is eliminated because
the feedback resistance., Rf is so large and hence it raises the gain in a linear manner and in turn
raises the output voltage. The offset control is provided by the resistance R
2
and is used to
position the output stylus pen. Gain adjustment is provided with the resistance Ro.
5.15.4.AUXILIARY AMPLIFIER:
Since the electrode impedances are not equal, a differential amplifier does not completely
reject the common mode signals. The common mode signals can be reduced to a minimum level
by means of adding an auxiliary amplifier between the driven right leg lead and the ECG unit.
By this way, the right leg is not connected to ground but it is connected to the output of the
auxiliary amplifier. If the body common mode voltage is different from zero, a summing network
produces the sum of all common mode voltages from all other electrodes and feeds that sum of
the voltages as input to inverting terminal of the auxiliary amplifier. Meanwhile its noninverting
terminal is grounded. The output of the auxiliary amplifier is connected to the right leg.
Therefore it drives the body to zero common voltage. Thus the common mode rejection ratio of
the overall system is increased. Further in the right leg electrode the current flow is reduced.
5.15.5.ISOLATED POWER SUPPLY:
The isolated power supply is used to give power to the bio-amplifier and by means of
that, the electrical safety for the patient is increased.
5.15.6.OUTPUT UINT:
The output unit is a cathode ray oscilloscope. Or a paper chart recorder. In case of paper
chart recorder, the power amplifier or pen amplifier supplies the required power to drive pen
motor that records the ECG trace on the wax coated heart sensitive paper. A position control on
the pen amplifier is used to position the pen at the center on the recording paper. The stylus pen
is heated electrically and the temperature of the stylus pen can be adjusted with a stylus heat
control. There is a marker stylus which is actuated by a push button and allows the technician to
mark a coded indication of the lead being recorded. The paper speed is about 25 mm/s or 50
mm/s. the faster speed of 50 mm/s is provided to allow better resolution of the QRS complex at
very high heart rates.
5.15.7.POWER SWITCH:
The power switch of the recorder has three positions. In the on position the powet to the
amplifier is turned on; but the paper drive is not running. In order to start the paper drive the
switch must be placed in the RUN position. In the off position, the ECG unit is in switched off
condition.
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5.16.Echocardiography
An echocardiogram. Image shows that the human heart has four chambers. Apical view - left
side of the heart to the right. Right side-up - heart's apex at bottom. The trace in the lower left
shows the cardiac cycle and the red mark the time in the cardiac cycle that the image was
captured.
An abnormal echocardiogram. Image shows a mid-muscular ventricular septal defect. The trace
in the lower left shows the cardiac cycle and the red mark the time in the cardiac cycle that the
image was captured. Colours are used to represent the velocity of the blood.
The echocardiogram is an ultrasound of the heart. Using standard ultrasound techniques, two-
dimensional slices of the heart can be imaged. The latest ultrasound systems now employ 3D
real-time imaging.
In addition to creating two-dimensional pictures of the cardiovascular system, the
echocardiogram can also produce accurate assessment of the velocity of blood and cardiac tissue
at any arbitrary point using Pulsed or Continuous wave Doppler ultrasound. This allows
assessment of cardiac valve areas and function, any abnormal communications between the left
and right side of the heart, any leaking of blood through the valves (valvular regurgitation), and
calculation of the cardiac output as well as the ejection fraction.
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Echocardiography was the first medical application of ultrasound. Echocardiography was also
the first application of intravenous contrast-enhanced ultrasound. This technique injects gas-
filled microbubbles into the venous system to improve tissue and blood delineation. Contrast is
also currently being evaluated for its effectiveness in evaluating myocardial perfusion. It can also
be used with Doppler ultrasound to improve flow-related measurements.
Echocardiography is usually performed by cardiologists or cardiac sonographers
5.16.1.Transthoracic echocardiogram
The standard echocardiogram is also known as a transthoracic echocardiogram, or TTE.
In this case, the echocardiography transducer (or probe) is placed on the chest wall (or thorax) of
the subject, and images are taken through the chest wall. This is a non-invasive, highly accurate
and quick assessment of the overall health of the heart. A cardiologist can quickly assess a
patient's heart valves and degree of heart muscle contraction (an indicator of the ejection
fraction).
The TTE is commonly used to help diagnose endocarditis. Diagnostic findings by the
Echocardiogram include definitive evidence of vegetation or thrombus on valves or other
endocardiac structures, abscesses, or disruption of a prosthetic heart valve.
The TTE is highly accurate for identifying vegetations, but the accuracy can be reduced in up to
20% of adults because of obesity, chronic obstructive pulmonary disease, chest-wall deformities,
or otherwise technically difficult patients. Transesophageal echocardiography, if available, may
be more accurate than TTE because it excludes the variables previously mentioned and allows
closer visualization of common sites for vegetations and other abnormalities. Transesophageal
echocardiography also affords better visualization of prosthetic heart valves.
Transesophageal echocardiogram
Another way to perform an echocardiogram is to insert a specialised scope containing an
echocardiography transducer (TEE probe) into the patient's esophagus, and record pictures from
there. This is known as a transesophageal echocardiogram, or TEE (TOE in the United
Kingdom). The advantages of TEE over TTE are usually clearer images. The transducer is closer
to the heart and doesn't have the ribs and lungs to deflect the ultrasound beam. Some structures
are better imaged with the TEE. These structures include the aorta, the pulmonary artery, the
valves of the heart, and the left and right atria. While TTE can be performed easily and without
pain for the patient, TEE may require light sedation and a local anesthetic lubricant for the
esophagus. Children are anesthetized. Unlike the TTE, the TEE is considered an invasive
procedure.
In some centers, sedation is used to ease the discomfort to the individual. The use of local
anesthetic agents and sedation can decrease the gag reflex, making the ultrasound probe easier to
pass into the esophagus. The transducer and cable are then coated in a lubricant, placed in the
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patients mouth, and then passed down the patient's throat. The individual is instructed to
swallow while the probe is being passed down, to prevent it from going into the trachea.
Although the placement of the thumb-wide transducer is uncomfortable, there are very few
complaints of gagging from the patient once the transducer is in the correct location.
6.Study of the brain
6.1.Fields of study
Neuroscience seeks to understand the nervous system, including the brain, from a biological and
computational perspective. Psychology seeks to understand behavior and the brain. The terms
neurology and psychiatry usually refer to medical applications of neuroscience and psychology
respectively. Cognitive science seeks to unify neuroscience and psychology with other fields that
concern themselves with the brain, such as computer science (artificial intelligence and similar
fields) and philosophy.
6.1.1.Methods of observation
6.1.2.Electrophysiology
Each method for observing activity in the brain has its advantages and drawbacks.
Electrophysiology allows scientists to record the electrical activity of individual neurons or
groups of neurons.
6.1.3.EEG
By placing electrodes on the scalp one can record the summed electrical activity of the cortex in
a technique known as electroencephalography (EEG). EEG measures the mass changes in
electrical current from the cerebral cortex, but can only detect changes over large areas of the
brain with very little sub-cortical activity.The abbreviation of electroencephalograph is called
EEG. It deals with the recording and study of electrical activity of the brain. EEGs are recorded
by means of electrode attracted to the skull of a patient the brain waves can be picked up and
recorded. Graded potentials are variations around the average value of the resting potential. Thus
the EEG potentials originate within the dendrite.
.6.1.4.MEG
Apart from measuring the electric field around the skull it is possible to measure the magnetic
field directly in a technique known as magnetoencephalography (MEG). This technique has the
same temporal resolution as EEG but much better spatial resolution, although admitedly not as
good as fMRI. The main advantage over fMRI is a direct relationship between neural activation
and measurement.
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6.1.5.fMRI and PET
Functional magnetic resonance imaging (fMRI) measures changes in blood flow in the brain, but
the activity of neurons is not directly measured, nor can it be distinguished whether this activity
is inhibitory or excitatory. fMRI is a noninvasive, indirect method for measuring neural activity
that is based on BOLD; Blood Oxygen Level Dependent changes. The changes in blood flow
that occurs in capillary beds in specific regions of the brain are thought to represent various
neuronal activities. Similarly, a positron emission tomography (PET), is able to monitor glucose
metabolism in different areas within the brain which can be correlated to the level of activity in
that region.
6.1.6.Other methods
Attempts have also been made to directly "read" the brain, which has been accomplished in a
rudimentary manner through a brain-computer interface. Brain activity can be detected by
implanted electrodes, raising the possibility of direct mind-computer interface. The reverse
method has been successfully demonstrated.
6.1.7.Other matters
Computer scientists have produced simulated neural networks loosely based on the
structure of neuron connections in the brain. Artificial intelligence seeks to replicate brain
functionalthough not necessarily brain mechanismsbut as yet has been met with limited
success.
Creating algorithms to mimic a biological brain is very difficult because the brain is not a static
arrangement of circuits, but a network of vastly interconnected neurons that are constantly
changing their connectivity and sensitivity. More recent work in both neuroscience and artificial
intelligence models the brain using the mathematical tools of chaos theory and dynamical
systems. Current research has also focused on recreating the neural structure of the brain with the
aim of producing human-like cognition and artificial intelligence.
6.2.ElectroEncephaloGraphy (EEG)
The recorded representation of bioelectric potential generated by neuronal
activity of the brain is called electroencephalogram(EEG). With the help of electrodes
attached to the skull of a patient, the brain waves can be picked up and recorded. EEG wave
form has a very complex pattern, which is much more difficult to recognize than the ECG.
The brain waves are the summation of neuronal depolarization in the brain. Due to stimuli
from the five senses as well as from the thought process on the surface of the brain, these
voltages are about 10 mV. Due to propagation through skull bone, they are attenuated to
levels from 1v to 100v,which are picked up by EEG electrodes. They are in the frequency
range from 0.5 to 3000hz.. These potentials vary with respect to position of electrode on the
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surface of skull. The waveform varies greatly with the location of the measuring electrodes
on the surface of the scalp. EEG potentials measured at the surface of the scalp, actually
represent the combined effect of potentials from a fairly wide region of the cerebral cortex
and from the various points beneath. During recording the electrodes are placed around the
frontal, parietal, temporal and occipital lobe of the lobes, the EEG waveforms is generally
affected by the mental activity of a person.
Evoked potentials are the potentials developed in the brain as the responses to external stimuli
like light, sound etc. the external stimuli is detected by the sense organs, which cause changes in
the electrical activity of the brain. Nowadays the term event related potential has been used
instead of evoked potential.
6.2.1.Brain Waves:
Wide variation among individuals and the lack of repeatability in a given person
from one person to another make the establishment of specific relationships. But some
characteristics EEG waveforms can be related to epileptic seizures and sleep. The EEG
waveforms obtained with the help of intensity and patterns of this electrical activity due to
overall level of excitation of the brain. This includes various activities of a person when in
alert condition, sleepy condition, tension condition etc.
Normally the brain waves are irregular, no general patterns can be discerned in the
EEG. But during abnormal conditions we can obtain the specific wave form.
The normal Brain waves that occur in the human being can be classified into Alpha,
Beta, delta and theta waves.
Brain waves Frequency
Delta wave below 3 hz
Theta wave from 3 hz to about 8hz .
Alpha wave from about 8hz to about 13hz .
Beta wave above 13hz .
Activity types
One second of EEG signal
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Historically four major types of continuous rhythmic sinusoidal EEG activity are recognized
(alpha, beta, delta and theta). There is no precise agreement on the frequency ranges for each
type.
- Delta is the frequency range up to 4 Hz and is often associated with the very young and
certain encephalopathies and underlying lesions. It is seen in stage 3 and 4 sleep.
Delta waves.
- Theta is the frequency range from 4 Hz to 8 Hz and is associated with drowsiness,
childhood, adolescence and young adulthood. This EEG frequency can sometimes be
produced by hyperventilation. Theta waves can be seen during hypnagogic states such as
trances, hypnosis, deep day dreams, lucid dreaming and light sleep and the preconscious
state just upon waking, and just before falling asleep.
Theta waves.
- Alpha (Berger's wave) is the frequency range from 8 Hz to 12 Hz. It is characteristic of
a relaxed, alert state of consciousness. Alpha rhythms are best detected with the eyes
closed. Alpha attenuates with drowsiness and open eyes, and is best seen over the
occipital (visual) cortex. An alpha-like normal variant called mu is sometimes seen over
the motor cortex (central scalp) and attenuates with movement, or rather with the
intention to move.
Alpha waves.
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- sensorimotor rhythm (SMR) is a middle frequency (about 1216 Hz) associated with
physical stillness and body presence.
- Beta is the frequency range above 12 Hz. Low amplitude beta with multiple and varying
frequencies is often associated with active, busy or anxious thinking and active
concentration. Rhythmic beta with a dominant set of frequencies is associated with
various pathologies and drug effects, especially benzodiazepines.
Beta waves.
- Gamma is the frequency range approximately 26100 Hz. Gamma rhythms appear to be
involved in higher mental activity, including perception, problem solving, fear, and
consciousness.
Gamma waves.
Rhythmic slow activity in wakefulness is common in young children, but is abnormal in
adults. In addition to the above types of rhythmic activity, individual transient waveforms such
as sharp waves, spikes, spike-and-wave complexes occur in epilepsy, and other types of
transients occur during sleep.
In the transition from wakefulness, through Stage I sleep (drowsiness), Stage II (light) sleep, to
Stage III and IV (deep) sleep, first the alpha becomes intermittent and attenuated, then
disappears. Stage II sleep is marked by brief bursts of highly rhythmic beta activity (sleep
spindles) and K complexes (transient slow waves associated with spindles, often triggered by an
auditory stimulus). Stage III and IV are characterized by slow wave activity. After a period of
deep sleep, the sleeper cycles back to stage II sleep and/or rapid eye movement (REM) sleep,
associated with dreaming. These cycles may occur many times during the night.
EEG under general anesthesia depends on the type of anesthetic employed. With halogenated
anesthetics and intravenous agents such as propofol, a rapid (alpha or low beta), nonreactive
EEG pattern is seen over most of the scalp, especially anteriorly; in some older terminology this
was known as a WAR (widespread anterior rapid) pattern, contrasted with a WAIS (widespread
slow) pattern associated with high doses of opiates. Anesthetic effects on EEG signals are
beginning to be understood at the level of drug actions on different kinds of synapses and the
circuits that allow synchronized neuronal activity
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6.3.Coma
In medicine, a coma (from the Greek - koma, meaning deep sleep) is a profound state of
unconsciousness. A comatose patient cannot be awakened, fails to respond normally to pain or
light, does not have sleep-wake cycles, and does not take voluntary actions. Coma may result
from a variety of conditions, including intoxication, metabolic abnormalities, central nervous
system diseases, acute neurologic injuries such as stroke, and hypoxia. It may also be
deliberately induced by pharmaceutical agents in order to preserve higher brain function
following another form of brain trauma.
The difference between coma and stupor is that a patient with coma cannot give a suitable
response to either noxious or verbal stimuli, whereas a patient in a stupor can give a crude
response, such as screaming, to an unpleasant stimulus.
Some psychiatric diseases appear similar to coma. Some forms of schizophrenia, catatonia, and
extremely severe major depression are responsible for behaviour that appears comatose.
Coma is also to be distinguished from the persistent vegetative state which may follow it. This is
a condition in which the individual has lost cognitive neurological function and awareness of the
environment but does have noncognitive function and a preserved sleep-wake cycle.
Spontaneous movements may occur and the eyes may open in response to external stimuli, but
the patient does not speak or obey commands. Patients in a vegetative state may appear
somewhat normal and may occasionally grimace, cry, or laugh.
Likewise, coma is not the same as brain death, which is the irreversible cessation of all brain
activity. One can be in a coma but still exhibit spontaneous respiration; one who is brain-dead,
by definition, cannot.
Coma is different from sleep; sleep is always reversible.
6.4.Distinctive phases of coma
Within coma itself, there are several categories that describe the severity of impairment.
Contrary to popular belief, a patient in a comatose state does not always lay still and quiet. They
may talk, walk, and perform other functions that may sometimes appear to be conscious acts, yet
are not.
Two scales of measurement frequently used in TBI diagnosis to determine the phase of
coma are the Glasgow Coma Scale and the Ranchos Los Amigos Scale. The GCS is a simple 15-
point scale used by medical professionals to assess severity of neurologic trauma, and establish a
prognosis. The RLAS is a more complex scale that describes up to eight separate levels of coma,
and is often used in the first few weeks or months of coma while the patient is under closer
observation, and when shifts between levels are more frequent.
There are several levels of coma, through which patients may or may not progress. As
coma deepens, responsiveness of the brain lessens, normal reflexes are lost, and the patient no
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longer responds to pain. The chances of recovery depend on the severity of the underlying cause.
A deeper coma alone does not necessarily mean a slimmer chance of recovery, because some
people in deep coma recover well while others in a so-called milder coma sometimes fail to
improve.
The outcome for coma and vegetative state depends on the cause, location, severity and
extent of neurological damage: outcomes range from recovery to death. People may emerge from
a coma with a combination of physical, intellectual and psychological difficulties that need
special attention. Recovery usually occurs gradually, with patients acquiring more and more
ability to respond. Some patients never progress beyond very basic responses, but many recover
full awareness. Gaining consciousness again is not instant: in the first days, patients are only
awake for a few minutes, and duration of time awake gradually increases.
Comas generally last a few days to a few weeks, and rarely last more than 2 to 5 weeks.
After this time, some patients gradually come out of the coma, some progress to a vegetative
state, and others die. Many patients who have gone into a vegetative state go on to regain a
degree of awareness. Others may remain in a vegetative state for years or even decades.
Predicted chances of recovery are variable due to different techniques used to measure the extent
of neurological damage. All the predictions are statistical rates with some level of chance for
recovery present: a person with a low chance of recovery may still awaken. Time is the best
general predictor of a chance for recovery, with the chances for recovery after 4 months of brain
damage induced coma being low (less than 15%), and full recovery being very low.
The most common cause of death for a person in a vegetative state is secondary infection such as
pneumonia which can occur in patients who lie still for extended periods.
6.5.ELECTROMYOGRAPHY:
Electromyography is the science of recording and interpreting the electrical activity of the
muscles action potentials. Meanwhile the recording of the peripheral nerves action potentials is
called electroneurography. The electrical activity of the under lying muscle can be measured by
placing surface electrodes on the skin. To determine whether the muscle is contracting or not, or
displaying on the CRO and loud speaker the action potentials spontaneously present in a muscle
or induced by voluntary contraction as a means of detecting the nature and location of the motor
unit lesions. So to record the action potentials of individual motor units, the needle electrode is
inserted into the muscle. The EMG indicates the amount of activity of a given muscle or a group
of muscles and not an individual nerve fiber.
The action potentials occur both positive and negative polarities at a given pair of
electrodes, so they may add or cancel each other. Thus EMG appears, very much like a random
noise waveform. The contraction of a muscle produces action potentials. Where there is
stimulation to a nerve fiber, all the muscle fiber contract simultaneously developing action
potentials. In a relaxed muscle, there is no action potential. EMG is usually recorded by using
surface electrodes or more often needle electrodes inserted directly into the muscle. The surface
electrodes pick-up the potentials produced by the contracting muscle fibers. The signal can then
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be amplified and displayed on the screen of an audio amplifier connected to the loud speaker.
The oscilloscope displays EMG waveforms. The tape recorder is included in the system to
facillate play-back and study of the EMG sound waveforms at a later convenient time. the
waveform can also be photographed from the CRT screen by using a synchronized camera.
The surface electrodes or needle electrodes pickup the potentials produced by the
contracting muscle fibers. The surface electrodes are from Ag-Agcl and are in disc shape. The
surface of the skin is cleaned and electrode paste is applied. The electrodes are kept in place by
means of elastic bands. By that way, the contact impedance is reduced below 10kiloohms. There
are two types of conventional electrodes: bipolar and unipolar type electrodes. In the case of
bipolar electrode, the potential difference between two surface electrodes resting on the skin is
measured. In case of unipolar electrode, the reference surface electrode is placed on the skin and
the needle electrode which acts as active electrode, is inserted into the muscle. Because of small
contact area, these unipolar electrodes have high impedances ranging from 0.5 to 100mega ohms.
With needle electrodes, it is possible to pickup action potentials from the selected nerves or
muscles and individual motor units. In the case of coaxial electrode which consists of an
insulated wire threaded through a hyperdermic needle with a oblique tip for easy penetration, the
surrounding steel jacket acts as reference and the metallic wire acts as exploring electrode. The
needle is inserted into the muscle further to record the action potentials for a single nerve
microelectrodes are used.
The amplitude of the EMG signals depends upon the type and placement of
electrodes used and the degree of muscular exertions. That is the surface electrode pick up many
Oscilloscope
Tape recorder
A.F.Amplifier
EMG
amplifier
Speaker
Block diagram of typical set up for EMG recording
Input
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overlapping spikes and produces an average voltage from various muscles and motor units. The
needle electrodes pick up the voltage from a single nerve fiber. Generally EMG signals range
from 0.1 to 0.5 mv. They may contain frequency components from 20 Hz to 10 KHz., which are
in the audio range, but using low pass filter, the electromyography restricts this frequency range
fro 20 Hz to 200 Hz for clinical purposes. The normal frequency of EMG is about 60 Hz.
Therefore the slow speed strip chart recorders are not useful and the signals are displayed on a
cathode ray oscilloscope and photographic recordings are made. Normally there are two cathode
ray tubes, one for viewing and other one for recording. A light sensitive paper moves over the
recording cathode ray tube and the image is produces on that paper. After developing it, one can
see the visible image. For continuous recording, the paper speed is about 5 to 25 cm/second. For
short duration it is about 50 to 400 cm/second. The paper width is about 10 cm. treading a
needle, and an array of facial expressions. Smooth muscles occur in the walls of internal body
organs and perform actions such as food through the intestines contracting the uterus (Womb) in
child birth and pumping blood through blood vessels.
6.6.ELECTRORETINOGRAPHY:
The recording and interpreting the electrical activity of eye is called electroretinography.
All sense organs are connected to the brain but the eye has a special relationship as the retina is
an extension of the cerebral cortex. Potentials within the eye may be recorded relatively easily
because of its exposed position. The cornea is about 20mv positive relative to the fundus of the
eye. The fundus is the back of the interior of the eye ball. If the illumination of the retina is
changed, the potential changes slightly in a complex manner. The recording of these changes is
called retinogram. A silver- silver chloride electrode on a contact lens and a distinct electrode on
the cheek are used to record the eye potential changes.
Electrode placement:
The bipolar recording technique is used. The exploring electrode is placed on a saline
filed contact lens. The contact lens is placed on a saline filled contact lens. The contact lens is
tightly attached to the eye. During eye movement there is no slip of contact lens by using
negative pressure (between the corneal cavity and the cornea) attachment techniques. The
common contact lenses used for corrections or cosmetic purposes ride on a tear film over the
cornea, do not follow eye movements well and are unsuitable for recording purposes. Therefore
specially made contact lenses used to record the action potentials of eye during flash of light
incident on eye.
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Recording Techniques:
When light falls on the retina, the absorption of photons by photo pigments localized in
the outer segment of the retinas photoreceptors is taking place. This causes the breakdown or
bleaching of photo pigments which results in the liberation of ions that cause a change in the
membrane potential. This in turn results in the development of action potential that is transmitted
down the optic nerve. This action potential is picked up the electrodes and are fed to the bio
amplifier and then to the recorder. The recording set up is similar to the ECG recorder.
Figure shows the typical eletroretinogram. Before the flash of light is incident on eye, there is a
constant d.c. horizontal line in the recorder. In response to a 2 seconds flash of light, a
retinogram is developed. Probably the curve originates from the pigment layer beyond photo
receptors (extra retinal).
The first part A of the response to a brief flash of light is due to the early receptor
potential (ERP) generated by the incident light which induces changes in the photo pigment
molecules. The second component part B with a delay of 1 to 5 milliseconds is due to later
receptor potential (LRP) produced by syruptic ending of the photoreceptors. This is the
maximum output of the receptors. The part C wave recorded with the off response of ERP and
LRP.
In the earlier recording of the eye potentials, the corneal electrodes were not used. Instead
the rotation of the contact lens was measure by means of a mirror (on contact lens) which reflects
the incident light on a moving photographic film or photo cell. After developing the
photographic film, we can see the image and from that we can get some informations about the
eye potentials. In the case of photocells, the output from the photocell was amplified and then
given to the recorder. There was also a nonoptical method for measuring contact lens rotation.
Two sets of magnetic coils, normal in the space and oscillating in phase quadrature at 4.8kHz
create crossed magnetic fields which excite two small search coils embedded in the contact lens.
Rotations of the eye cause induced voltages of few millivolts, which can give information about
the eye potential.
Time
Action
potential
B
A C
D
1 mV
Light on
1 Sec
Electroretinogram waveform
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The diseases which affect the steady potential of the eye.
- The effects of certain drugs on the eye movement system can be determined.
- The state of semicircular canalizes analyzed by EOG.
- Diagnosis of the neurological disorders may be possible.
- The level of anesthesia can be indicated by characteristic eye movements.
TELEMEDICINE
7.1 Introduction :
7.1.1 Wireless telemetry:
Wireless telemetry gives analysis of the physiological data of man or animal under
normal conditions and in natural surroundings without any discomfort or obstruction to the
person or animal
Biotelemetry is the branch of biomedical instrumentation that deals with the measuring
physiological variables to a method of transmission of resulting data. Telemetry is most
convenient during transportation within the hospital area as well for the continuous monitoring
of patients sent to other wards or clinics for check-up or therapy.
Biotelemetry is the measurement of biological parameters over a distance. The means of
transmitting the data from the point of generation to the point of reception can take many forms.
Measurements can be applied to two categories.
- Biological variables such as EEG, ECG and EMG.
- Physiological variables that require transducers such as blood pressure,
gastrointestinal pressure, blood flow and temperatures.
In first category, a signal is obtained directly in electrical form, whereas the second category
requires a type of excitation. The physiological parameters are eventually measured as variations
of resistance, inductance or capacitance. The differential signals obtained from these variations
can be calibrated to represent pressure, flow, temperature and so on.
The analog signal that is obtained from the electrodes (the signal may be in the form of
voltage, current etc) is converted into a form or code capable of being transmitted at the
transmitter end with the help of transmitter set up.
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The transmitter end comprises of transducer that converts physical signals into analog
electrical signal. That electrical signal has to be amplified with the help of preamplifier set up.
The amplified signal has been modulated with the help of modulator and encoder, this processed
signal is transmitted through the multiplexer circuit.
At the receiver end the signal is converted back into its original form. The receiver end
comprises of demultiplexer, decoder, and demodulator circuit.
The demultiplexer circuit demultiplexes the received signal. Now this demultiplexed
signal is passed through the decoder and demodulator. Finally the original signal is retrieved
back for analyzing purpose.
Currently the most widespread use of biotelemetry for biotelemetric potentials is in the
form of the electrocardiogram. A simple set up is sufficient in the transmitting end. That set up
comprises of only electrodes and amplification circuit that is needed to prepare the signal for
transmission.
7.1.2 Telemedicine:
It is the application of telecommunications and computer technology to deliver health
care from one location to another. This telemedicine uses the modern information technology to
deliver timely health services to those in need by the electronic methods. The patient may be
present at the remote location. In that location, the specialized doctors are not there means, we
can give protection to the life of the patient with the help of this telemedicine. Nowadays for
investigation purpose only, we are using this telemedicine. In future with the help of this set up
and robot, the doctor can able to do operation for the needed patient who is present in remote
location.
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Components of biotelemetry system
:
Subject
Direct
biopotential
Transducer
Processor
Amplifier
Exciter
Carrier
Modulator
Block Diagram of a Biotelemetry transmitter
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7.2 Modulation systems:
Wireless telemetry system uses modulating systems for transmitting biomedical signals.
Two modulators are used here. A lower frequency sub-carrier is employed in addition to very-
high frequency (VHF). This transmits the signal from the transmitter. The purpose behind this
double modulation , it gives better interference free performance in transmission, and this
enables the reception of low frequency biological signals. The submodulators can be a FM
(frequency modulation) system, or a PWM (pulse width modulation) system or a final
modulator is practically always an FM system.
7.2 Frequency modulation ( FM ):
In FM systems, the signal can be trasnsmitted by varying the instantaneous frequency in
connection with the signal to be modulated on the wave. Here the amplitude of the signal t(plus
carrier wave) is constant. The rate at which the instantaneous frequency varies is the modulating
frequency. The magnitude to which the carrier frequency varies away from the centre frequency
is called frequency deviation. This is proportional to the modulating signal. Generally FM
signal is produced by controlling the frequency of an oscillator by the amplitude of the
modulating voltage. The frequency of oscillations for most oscillators depend on a particular
value of capacitance.
Tuner
Chart Recorder
or Oscilloscope
Tape Recorder
Demodulator
Receiver Storage Display units
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In the above diagram, the tuned oscillator serves as a frequency modulator. The diode used here
is a varactor diode. The varactor diode is operating in a reverse biased mode, because of this;
the varactor diode gives a depletion layer capacitance to the tank circuit.
This capacitance is a function of the reverse biased voltage across the diode and therefore
produces an FM wave with modulating signal applied.
7.2.1 Pulse width Modulation (PWM):
PWM method has an advantage of being less perspective to distortion and noise. Figure
shows a typical pulse width modulator, transistor q1 and Q2 from free running multivibrator.
Transistors Q3 and Q4 provide constant current sources for charging the timing capacitors
C1 and C and driving transistors Q1 and Q. when Q1 is off and Q is on , capacitor C21
chrges through R1 to the amplitude of the modulating voltage e
m .
the other side of this capacitor
is connected to the base voltage of Q2 drops from approximately zero to e
m
. transistor Q2 will
remain off until the base voltage charges to zero volt. Since the charging current is constant at I,
the time required to charge C2 and restore the circuit to the initial stage is
T2 = (C2/I ).e
m
Similarly, the time that the circuit remains in the original stage is
T1 = ( C1/I ).e
m
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7.2.2 Choice of radio carrier frequency:
In every country, there are regulations governing the use of only certain frequency and
bandwidth for medical telemetry. Therefore, the permission to operate a particular telemetry
system needs to be obtained from the postal department of the country concerned. The
transmitter is typically of 50 ohms, which can give a transmission range of about 1.5 Km in the
open flat country. The range will be less in built-up areas. In USA, two frequency bands have
been designated for short range medical telemetry work by the FCC ( federal communication
commision). The lower frequency band of 174-216 MHz, coincides with the VHF television
broad cast band(channels 7-13) therefore the output of the telemetry transmitter must be limited
to avoid interference with TV sets. In higher frequency band of 450-470 MHz, greater
transmitter power is allowed but an FCC license has to be obtained for operating the system.
Radio waves can travel through most of non-conducting material such as air, wood and
plaster with relative ease. But these radio waves are hindered, blocked or reflected by most
conductive material and by concrete. This is due to the presence of reinforced steel in the
concrete buildings. Because of this phenomenon, transmission may be lost or be of poor quality
P
Q
W
W
Variation of Pulse width with amplitude
W= Pulse width generated by the multi-vibrator
P= Variable pulse width, in accordance with input signal
Q = off Period, which also gets varied.
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when a patient with a telemetry transmitter moves in an environment with a concrete wall or
behind a structure. Reception may also get affected by radio frequency reception or null spots.
One of the important problems can be minimized by the careful selection of transmitter
frequencies by the use of suitable antenna system and by the equipment design.
Based on the output power and frequency obtained, it is possible for us to decide the
range of the radio system. Care should be taken for designing the receiver and antenna. Only the
transmitted signal from the remote location can be analyzed properly otherwise it is difficult for
the doctor to give proper medicine.
The transmitter:
The commonly used FM transmitter is shown below. This circuit can be used for medical
telemetry also. The circuit comprises of a transistor, feedback circuit, and a tank circuit. The
transisytor used here is a grounded base colpitts R.F. oscillator with L
1
, C
1
, C
2
as the tank circuit.
A capacitive divider circuit is plced in the collector circuit, that is formed with the
help of C1 and C2. inductor L1 functions both as a tuning coil and a transmitting antenna.
With the help of this set up, a positive feedback is provided to the amplifier circuit. We can able
to set the transmission frequency to a precise level. This can be done by adjusting the trim
capacitor C2. with this set up, we can able to set the frequencyrange of 88 to 188 MHz.
Frequency modulation can be achieved by variation in the operating point of the transistor,
which in turn varies its collector capacitance, thus changing the resonant frequency of the
tranistor circuit. The operating point can be changed by the sub-carrier input. Thus the
transmitter,s output consists of an RF signal, tuned in the FM broad cast band and frequency
modulated by the sub-carrier oscillator (SCO), which in turn is frequency modulated by the
physiological signals of interest.
Transmitter circuit diagram:
Inductor
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The Receiver:
The receiver can be a common broadcast receiver with a sensitivity of 1 microvolt. The
output of the hf unit of the receiver is fed to the sub cab-modulator HF unit of the receiver is fed
to the sub-modulator to extract the modulating signal. In a FM/FM system, the sub-modulator
first converst the FM signal into an AM signal. This is followed by an AM detector, which
demodulates the newly created AM waveform. With this arrangement, the output is linear with
frequency deviation only for small frequency deviations. Other types of detectors can be used to
improve the linearity. Two major problems that has been faced in biotelemetry at the system
interfaces. The first problem is the interface between the biological system and the electrical
system.
The second problem is the interface between transmitter and receiver.
7.3.Radio Pill
The earliest biotelemetry units was the endoradiosonde, developed by Mackay and
Jacobson. The pressure sensing electrode is a radio pill less than 1 cm
3
.in volume. This radio pill
can be swallowed by the patient. Radio pill now travels through the gasterointestinal tract on the
way of passing into the gastrointentinal tract, the radio pill is capable of measuring various
parameters that are available in the tract. With the help of radio pill type devices, it is possible
for us to measure or sense temperature, pH, enzyme activity, and oxygen tesion values. These
measurements can be made in associated with transducers. Pressure can be sensed by using
variable inductance, temperature can be measured by using temperature-sensitive transducer.
7.4.NERVE AND MUSCLE STIMULATORS:
Stimulators are the devices which are used to stimulate innervated muscles denervated
muscles and nerves. further these are used for the treatment of paralysis with totally or partially
denervated muscles, for the treatment of pain. muscular spasm and peripheral circulatory
disturbances. this technique is called electrotherapy which uses low volt, low frequency impulse
currents.
7.4.1.STIMULATION OF NERVES:
There is normally a potential difference of about 100mv across a nerve membrane. if this
potential is reversed for more than about 20 milliseconds, the nerves will be stimulated and an
action potential will be propagated along the nerve fiber.
the nervous system is the body's internal, electrochemical, communication network. its
main poarts are the brain and spinal cord from the central nervous system (CNS) the body's chief
controlling and coordinating centres. Billions of long neurons, many grouped as nerves, make up
the peripheral nervous system, transmitting nerve impulses between the CNS and other regions
of the body. Each neurons has threee parts: a cell body, branching dendrites that receive
chemical signals from other neurons, and a tube -like axon that conveys these signals as
electrical impulses.
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Types of neurons:
Three types of neurons are there. they are Multipolar, unipolar, bipolar.
Types of nerve ending:
free nerve ending, Meissner's corpuscle. Merkel's disc. Ruffini corpuscle, Pacinian
corpuscle.
7.4.2.ACCUPUNCTURE:
Accu-means needle, puncture- means making a highly concentrated presssure over the
skin, in order to relief the pain over the partiular area of the skin. This kind of treatment is
popular in CHINA from 2600B.C. onwards. in accupuncture, care should be taken for the
patient, not for the diseases. iin our body electric energy is there. It is possible for us to adjust the
electric energy in proper way. 12 paths are there in our body. in these 12 paths 900 needle points
are there. in these points, with the help of stainless steel needle we are puncturing our body. by
doing like this we can increase or decrease the electric energy in our body. In olden days people
had used this acupuncture in place of anasthesia. With the help of these acupunctre we can stop
the poain information, which passes to our brain. In our heart there are no nerves. so if we are
acupuncturing our heart means, we dont feel no pain. With the help of this accupunctur , we can
stimulate our nerves. nowadays with the help of electric current these nerves are stimulated.
7.4.3.DIFFERENT TYPES OPF WAVEFORMS USED IN
STIMULATOR(ELECTROTHERAPY)
Various types of waveforms are used for stimulation of nerves and muscles to carry out
treatment of various diseases.
(i) Galvanic current:
galvanic current is a constant or direct current. the maximum amount of current passed
through the body is about 0.3 to 0.5 mA/cm2 of electrode surface. the duration of the passage of
current is about 10 to 20 minutes. The passage of current creates the movement of ions. it is used
for the preliminary treatment of atonic paralysis and for the disturbance of blood flow in the
arteries.
(ii) Interrupted galvanic current:
Interrupted galvanic current pulses are a series of negative going rectangular pulses. the
pulse duration is about 100 milliseconds with a repetition rate is between 12 per minute and 70
per minute. A silghtly different form of interrupted galvanic pulses is the triangular wavepulses.
fig shows the unidirectional interrupted galvanic pulses which create ionization of the skin of the
patient and produce discomfort and inflammation. it is overcome by the application of a positive
current in between the negative pulses proportional to the time interval.
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(iii) Faradic current:
Faradic current pulses are usually between 50 per second in duration with a triangular
waveform as shown in fig (b). The repetition rate is invariably 50 per second. Faradic current can
produce muscular contractions. There is no ion movement due to the passage of faradic current.
This is used primarily for the treatment of muscle weakness. There are two types of faradic
current pulses , plain faddism is a train of faradic pulses of unvarying amplitude. These are rarely
used. Surged faradism is a series of surges of pulses shown in fig (c). Thus the amplitude of the
pulses applied to the patient increases in a slow manner and the number of surges per minute is
known as contraction rate. these faradic pulses are mainly used in the treatment of functional
paralysis and spasm. the muscular contraction occurs for each surge which gradually increases in
intensity from zero to maximum at the desired rate for muscular contraction, and relaxation of
muscles occurs when the surge ceases. Each surge has duration of 1500ms and approximately 70
impulses. its repetition rate is about 2 to 3 seconds.
(iv) Exponential current:
Fig(d) shows the exponential pulses used for the treatment of severe paralysis. By this
kind of pulses, the surrounding healthy muscles even in the immediate neighborhood of the
diseases be varied to provide selective stimulation.
Radiation therapy
Radiation therapy:
Radiation therapy (also called radiotherapy, x-ray therapy, or irradiation) is the
use of a certain type of energy (called ionizing radiation) to kill cancer cells and shrink
tumors. Radiation therapy injures or destroys cells in the area being treated (the target
tissue) by damaging their genetic material, making it impossible for these cells to
continue to grow and divide. Although radiation damages both cancer cells and normal
cells, most normal cells can recover from the effects of radiation and function properly.
The goal of radiation therapy is to damage as many cancer cells as possible, while
limiting harm to nearby healthy tissue.
Uses of radiation therapy:
Radiation therapy may be used to treat almost every type of solid tumor, including
cancers of the brain, breast, cervix, larynx, lung, pancreas, prostate, skin, spine, stomach,
uterus, or soft tissue sarcomas. Radiation can also be used to treat leukemia and
lymphoma (cancers of the blood-forming cells and lymphatic system, respectively).
Radiation dose to each site depends on a number of factors, including the type of cancer
and whether there are tissues and organs nearby that may be damaged by radiation.
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For some types of cancer, radiation may be given to areas that do not have evidence of
cancer. This is done to prevent cancer cells from growing in the area receiving the
radiation. This technique is called prophylactic radiation therapy.
Radiation therapy also can be given to help reduce symptoms such as pain from cancer
that has spread to the bones or other parts of the body. This is called palliative radiation
therapy.
Difference between external radiation therapy and internal radiation therapy:
Radiation may come from a machine outside the body (external radiation), may
be placed inside the body (internal radiation), or may use unsealed radioactive materials
that go throughout the body (systemic radiation therapy). The type of radiation to be
given depends on the type of cancer, its location, how far into the body the radiation will
need to go, the patients general health and medical history, whether the patient will have
other types of cancer treatment, and other factors.
Most people who receive radiation therapy for cancer have external radiation. Some
patients have both external and internal or systemic radiation therapy, either one after the
other or at the same time.
- External radiation therapy usually is given on an outpatient basis; most patients
do not need to stay in the hospital. External radiation therapy is used to treat most
types of cancer, including cancer of the bladder, brain, breast, cervix, larynx, lung,
prostate, and vagina. In addition, external radiation may be used to relieve pain or
ease other problems when cancer spreads to other parts of the body from the primary
site.
- Intraoperative radiation therapy (IORT) is a form of external radiation
that is given during surgery. IORT is used to treat localized cancers that cannot
be completely removed or that have a high risk of recurring (coming back) in
nearby tissues. After all or most of the cancer is removed, one large, high-
energy dose of radiation is aimed directly at the tumor site during surgery
(nearby healthy tissue is protected with special shields). The patient stays in the
hospital to recover from the surgery. IORT may be used in the treatment of
thyroid and colorectal cancers, gynecological cancers, cancer of the small
intestine, and cancer of the pancreas. It is also being studied in clinical trials
(research studies) to treat some types of brain tumors and pelvic sarcomas in
adults.
- Prophylactic cranial irradiation (PCI) is external radiation given to the
brain when the primary cancer (for example, small cell lung cancer) has a high
risk of spreading to the brain.
- Internal radiation therapy (also called brachytherapy) uses radiation that is
placed very close to or inside the tumor. The radiation source is usually sealed in a
small holder called an implant. Implants may be in the form of thin wires, plastic
tubes called catheters, ribbons, capsules, or seeds. The implant is put directly into
the body. Internal radiation therapy may require a hospital stay.
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Internal radiation is usually delivered in one of two ways, each of which is
described below. Both methods use sealed implants.
- Interstitial radiation therapy is inserted into tissue at or near the tumor
site. It is used to treat tumors of the head and neck, prostate, cervix, ovary,
breast, and perianal and pelvic regions. Some women treated with external
radiation for breast cancer receive a booster dose of radiation that may use
interstitial radiation or external radiation.
- Intracavitary or intraluminal radiation therapy is inserted into the
body with an applicator. It is commonly used in the treatment of uterine cancer.
Researchers are also studying these types of internal radiation therapy for other
cancers, including breast, bronchial, cervical, gallbladder, oral, rectal, tracheal,
uterine, and vaginal.
- Systemic radiation therapy uses radioactive materials such as iodine 131 and
strontium 89. The materials may be taken by mouth or injected into the body.
Systemic radiation therapy is sometimes used to treat cancer of the thyroid and adult
non-Hodgkin lymphoma. Researchers are investigating agents to treat other types of
cancer.
Cancer patients receiving radiation therapy are often concerned that the treatment will
make them radioactive. The answer to this question depends on the type of radiation
therapy being given.
External radiation therapy will not make the patient radioactive. Patients do not need to
avoid being around other people because of the treatment.
Internal radiation therapy (interstitial, intracavitary, or intraluminal) that involves sealed
implants emits radioactivity, so a stay in the hospital may be needed. Certain precautions
are taken to protect hospital staff and visitors. The sealed sources deliver most of their
radiation mainly around the area of the implant, so while the area around the implant is
radioactive, the patients whole body is not radioactive.
Systemic radiation therapy uses unsealed radioactive materials that travel throughout the
body. Some of this radioactive material will leave the body through saliva, sweat, and
urine before the radioactivity decays, making these fluids radioactive. Therefore, certain
precautions are sometimes used for people who come in close contact with the patient.
The patients doctor or nurse will provide information if these special precautions are
needed.
Dosage of radiation:
The amount of radiation absorbed by the tissues is called the radiation dose (or
dosage). Before 1985, dose was measured in a unit called a rad (radiation absorbed
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dose). Now the unit is called a gray (abbreviated as Gy). One Gy is equal to 100 rads; one
centigray (abbreviated as cGy) is the same as 1 rad.
Different tissues can tolerate various amounts of radiation (measured in centigrays). For
example, the liver can receive a total dose of 3,000 cGy, while the kidneys can tolerate
only 1,800 cGy. The total dose of radiation is usually divided into smaller doses (called
fractions) that are given daily over a specific time period. This maximizes the destruction
of cancer cells while minimizing the damage to healthy tissue.
The doctor works with a figure called the therapeutic ratio. This ratio compares the
damage to the cancer cells with the damage to healthy cells. Techniques are available to
increase the damage to cancer cells without doing greater harm to healthy tissues.
Sources of energy for external radiation therapy:
The energy (source of radiation) used in external radiation therapy may come from the
following:
- X-rays or gamma rays, which are both forms of electromagnetic radiation.
Although they are produced in different ways, both use photons (packets of energy).
- X-rays are created by machines called linear accelerators. Depending on
the amount of energy the x-rays have, they can be used to destroy cancer cells
on the surface of the body (lower energy) or deeper into tissues and organs
(higher energy). Compared with other types of radiation, x-rays can deliver
radiation to a relatively large area.
- Gamma rays are produced when isotopes of certain elements (such as
iridium and cobalt 60) release radiation energy as they break down. Each
element breaks down at a specific rate and each gives off a different amount of
energy, which affects how deeply it can penetrate into the body. (Gamma rays
produced by the breakdown of cobalt 60 are used in the treatment called the
gamma knife,)
- Particle beams use fast-moving subatomic particles instead of photons.
This type of radiation may be called particle beam radiation therapy or
particulate radiation. Particle beams are created by linear accelerators,
synchrotrons, and cyclotrons, which produce and accelerate the particles
required for this type of radiation therapy. Particle beam therapy uses
electrons, which are produced by an x-ray tube (this may be called
electron-beam radiation); neutrons, which are produced by radioactive
elements and special equipment; heavy ions (such as protons and helium);
and pi-mesons (also called pions), which are small, negatively charged
particles produced by an accelerator and a system of magnets. Unlike x-
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rays and gamma rays, some particle beams can penetrate only a short
distance into tissue. Therefore, they are often used to treat cancers located
on the surface of or just below the skin.
- Proton beam therapy is a type of particle beam radiation therapy.
Protons deposit their energy over a very small area, which is called the Bragg
peak. The Bragg peak can be used to target high doses of proton beam therapy
to a tumor while doing less damage to normal tissues in front of and behind the
tumor. Proton beam therapy is available at only a few facilities in the United
States. Its use is generally reserved for cancers that are difficult or dangerous to
treat with surgery (such as a chondrosarcoma at the base of the skull), or it is
combined with other types of radiation. Proton beam therapy is also being used
in clinical trials for intraocular melanoma (melanoma that begins in the eye),
retinoblastoma (an eye cancer that most often occurs in children under age 5),
rhabdomyosarcoma (a tumor of the muscle tissue), some cancers of the head
and neck, and cancers of the prostate, brain, and lung.
The sources of energy for internal radiation.
The energy (source of radiation) used in internal radiation comes from the radioactive
isotope in radioactive iodine (iodine 125 or iodine 131), and from strontium 89,
phosphorous, palladium, cesium, iridium, phosphate, or cobalt. Other sources are being
investigated.
Stereotactic radiosurgery and stereotactic radiotherapy
Stereotactic (or stereotaxic) radiosurgery uses a large dose of radiation to
destroy tumor tissue in the brain. The procedure does not involve actual surgery. The
patients head is placed in a special frame, which is attached to the patient skull. The
frame is used to aim high-dose radiation beams directly at the tumor inside the patients
head. The dose and area receiving the radiation are coordinated very precisely. Most
nearby tissues are not damaged by this procedure.
Stereotactic radiosurgery can be done in one of three ways. The most common technique
uses a linear accelerator to administer high-energy photon radiation to the tumor (called
linac-based stereotactic radiosurgery). The gamma knife, the second most common
technique, uses cobalt 60 to deliver radiation. The third technique uses heavy charged
particle beams (such as protons and helium ions) to deliver stereotactic radiation to the
tumor.
Stereotactic radiosurgery is mostly used in the treatment of small benign and malignant
brain tumors (including meningiomas, acoustic neuromas, and pituitary cancer). It can
also be used to treat other conditions (for example, Parkinson disease and epilepsy). In
addition, stereotactic radiosurgery can be used to treat metastatic brain tumors (cancer
that has spread to the brain from another part of the body) either alone or along with
whole-brain radiation therapy. (Whole-brain radiation therapy is a form of external
radiation therapy that treats the entire brain with radiation).
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Stereotactic radiotherapy uses essentially the same approach as stereotactic
radiosurgery to deliver radiation to the target tissue. However, stereotactic radiotherapy
uses multiple small fractions of radiation as opposed to one large dose. Giving multiple
smaller doses may improve outcomes and minimize side effects. Stereotactic
radiotherapy is used to treat tumors in the brain as well as other parts of the body.
Clinical trials are under way to study the effectiveness of stereotactic radiosurgery and
stereotactic radiotherapy alone and in combination with other types of radiation therapy.
- Three-dimensional (3D) conformal radiation therapy. Traditionally,
the planning of radiation treatments has been done in two dimensions
(width and height). Three-dimensional (3D) conformal radiation therapy
uses computer technology to allow doctors to more precisely target a
tumor with radiation beams (using width, height, and depth). Many
radiation oncologists use this technique. A 3D image of a tumor can be
obtained using computed tomography (CT), magnetic resonance imaging
(MRI), positron emission tomography (PET), or single photon emission
computed tomography (SPECT). Using information from the image,
special computer programs design radiation beams that conform to the
shape of the tumor. Because the healthy tissue surrounding the tumor is
largely spared by this technique, higher doses of radiation can be used to
treat the cancer. Improved outcomes with 3D conformal radiation therapy
have been reported for nasopharyngeal, prostate, lung, liver, and brain
cancers.
- Intensity-modulated radiation therapy (IMRT). IMRT is a new type of 3D
conformal radiation therapy that uses radiation beams (usually x-rays) of varying
intensities to deliver different doses of radiation to small areas of tissue at the same
time. The technology allows for the delivery of higher doses of radiation within the
tumor and lower doses to nearby healthy tissue. Some techniques deliver a higher
dose of radiation to the patient each day, potentially shortening the overall treatment
time and improving the success of the treatment. IMRT may also lead to fewer side
effects during treatment.
The radiation is delivered by a linear accelerator that is equipped with a multileaf
collimator (a collimator helps to shape or sculpt the beams of radiation). The
equipment can be rotated around the patient so that radiation beams can be sent from
the best angles. The beams conform as closely as possible to the shape of the tumor.
Because IMRT equipment is highly specialized, not every radiation oncology center
uses IMRT.
This new technology has been used to treat tumors in the brain, head and neck,
nasopharynx, breast, liver, lung, prostate, and uterus. However, IMRT is not
appropriate or necessary for every patient or tumor type. Long-term results
following treatment with IMRT are becoming available.
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Low-LET and high-LET radiation.
Linear energy transfer (LET) describes the rate at which a type of radiation deposits
energy as it passes through tissue. Higher levels of deposited energy cause more cells to
be killed by a given dose of radiation therapy. Different types of radiation have different
levels of LET. For example, x-rays, gamma rays, and electrons are known as low-LET
radiation. Neutrons, heavy ions, and pions are classified as high-LET radiation.
Most high-LET radiation is investigational treatment. The cost of the equipment and the
amount of specialized training needed to perform high-LET radiation therapy restrict its
use to only a few facilities in the United States.
Radiation treatment for the patient:
Many health care providers help to plan and deliver radiation treatment to the patient.
The radiation therapy team includes the radiation oncologist, a doctor who specializes in
using radiation to treat cancer; the dosimetrist, who determines the proper radiation dose;
the radiation physicist, who makes sure that the machine delivers the right amount of
radiation to the correct site in the body; and the radiation therapist, who gives the
radiation treatment. Often, radiation treatment is only one part of the patients total
therapy. Combined modality therapy, the use of radiation with drug therapy, is commonly
used.
The radiation oncologist also works with the medical or pediatric oncologist, surgeon,
radiologist (a doctor who specializes in creating and interpreting pictures of areas inside
the body), pathologist (a doctor who identifies diseases by studying cells and tissues
under a microscope), and others to plan the patients total course of therapy. A close
working relationship between the radiation oncologist, medical or pediatric oncologist,
surgeon, radiologist, and pathologist is important in planning the total therapy.
Importance of treatment planning.
Because there are so many types of radiation and many ways to deliver it,
treatment planning is a very important first step for every patient who will have radiation
therapy. Before radiation therapy is given, the patients radiation therapy team determines
the amount and type of radiation the patient will receive.
If the patient will have external radiation, the radiation oncologist uses a process called
simulation to define where to aim the radiation. During simulation, the patient lies very
still on an examining table while the radiation therapist uses a special x-ray machine to
define the treatment port or fieldthe exact place on the body where the radiation will be
aimed. Most patients have more than one treatment port. Simulation may also involve CT
scans or other imaging studies to help the radiation therapist plan how to direct the
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radiation. The simulation may result in some changes to the treatment plan so that the
greatest possible amount of healthy tissue can be spared from receiving radiation.
The areas to receive radiation are marked with either a temporary or permanent marker,
tiny dots or a tattoo showing where the radiation should be aimed. These marks are also
used to determine the exact site of the initial treatments if the patient should need
radiation treatment later.
Depending on the type of radiation treatment, the radiation therapist may make body
molds or other devices that keep the patient from moving during treatment. These are
usually made from foam, plastic, or plaster. In some cases, the therapist will also make
shields that cannot be penetrated by radiation to protect organs and tissues near the
treatment field.
When the simulation is complete, the radiation therapy team meets to decide how much
radiation is needed (the dose of radiation), how it should be delivered, and how many
treatments the patient should have.
Radiosensitizers and Radioprotectors
Radiosensitizers and radioprotectors are chemicals that modify a cells response
to radiation. Radiosensitizers are drugs that make cancer cells more sensitive to the
effects of radiation therapy. Several compounds are under study as radio sensitizers. In
addition, some anticancer drugs, such as 5-fluorouracil and cisplatin, make cancer cells
more sensitive to radiation therapy.
Radioprotectors (also called radioprotectants) are drugs that protect normal
(noncancerous) cells from the damage caused by radiation therapy. These agents promote
the repair of normal cells that are exposed to radiation. Amifostine (trade name Ethyol)
is the only drug approved by the U.S. Food and Drug Administration (FDA) as a
radioprotector. It helps to reduce the dry mouth that can occur if the parotid glands
(which help to produce saliva and are located near the ear) receive a large dose of
radiation. Additional studies are under way to determine whether amifostine is effective
when used with radiation therapy to treat other types of cancer. Other compounds are also
under study as radioprotectors.
Uses of radio pharmaceuticals:
Radiopharmaceuticals, also known as radionucleotides, are radioactive drugs used
to treat cancer, including thyroid cancer, cancer that recurs in the chest walls and pain
caused by the spread of cancer to the bone (bone metastases). The most commonly used
radiopharmaceuticals are samarium 15 (Quadramet) and strontium 89 (Metastron).
These drugs are approved by the FDA to relieve pain caused by bone metastases. Both
agents are given intravenously (by injection into a vein), usually on an outpatient basis;
sometimes they are given in addition to external beam radiation. Other types of
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radiopharmaceuticals, such as phosphorous 32, rhodium 186, and gallium nitrate, are not
used as frequently. Still other radiopharmaceuticals are under investigation.
New approaches to radiation therapy:
Hyperthermia, the use of heat, is being studied in conjunction with radiation
therapy. Researchers have found that the combination of heat and radiation can increase
the response of some tumors.
Researchers are also studying the use of radio labeled bodies to deliver doses of radiation
directly to the cancer site (radio-immunotherapy). Antibodies are highly specific proteins
that are made by the body in response to the presence of antigens (substances recognized
as foreign by the immune system). Some tumor cells contain specific antigens that trigger
the production of tumor-specific antibodies. Large quantities of these antibodies can be
made in the laboratory and attached to radioactive substances (a process known as
radiolabeling). Once injected into the body, the antibodies seek out cancer cells, which
are destroyed by the radiation. This approach can minimize the risk of radiation damage
to healthy cells.
The success of this technique depends on identifying appropriate radioactive substances
and determining the safe and effective dose of radiation that can be delivered in this way.
Two radioimmunotherapy treatments, ibritumomab tiuxetan (Zevalin) and tositumomab
and iodine 131 tositumomab (Bexxar), have been approved for advanced adult non-
Hodgkins lymphoma (NHL). Clinical trials of radioimmunotherapy are under way with a
number of cancers, including leukemia, NHL, colorectal cancer, and cancers of the liver,
lung, brain, prostate, thyroid, breast, ovary, and pancreas.
THERMOGRAPH:
Need for the Thermography:
Thermograph has a number of distinct advantages over other imaging systems. It is
completely non- invasive, there is no contact between the patient and system as with echography,
and there is no radiation hazard as with x-rays. A thermograph is a real-time system, changes can
be followed as fast as at a rate if one study per second.
Classification of thermography:
Based on detection of the thermal radiation from the skin sreas, we can classify the
thermograph into three methods. They are
Infrared thermograph
Liquid crystal thermograph
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Microwave themograph.
Thermo gram:
Thermo gram is a record of the infrared heat waves that are emitted by the body. it gives a visual
display of the hot and cold areas of the whole body. The technique of obtaining a thermo gram is
known as thermograph.
Thermographic equipment:
Thermographic equipment incorporate scanning systems which enable the infrared radiation
emitted from the surface of the skin with in the field of view to be focused on to an infrared
detector. The equipment used in the thermography basically consists of two units. A special
infrared camera that scans the object and a display unit for displaying the thermal picture on the
screen.
NETD:
NETD is nothing but Noise Equivalent Temperature Difference (NETD). It is the figure
of merit for the thermographic imaging system. This is usually called minimum resolution.
Resolution of the thermographic system:
The thermal and spatial resolution of a thermographic system is determined by the optical
parameters, detector performance. Preamplifiers noise, the signal processing system, the picture
presentation and evaluation systems. Thermo gram:
Problem of medical thermography:
For comparing the results of successive thermo graphic examinations, it is essential that
the results are standardized and quantified. In the earlier thermographic equipment the
thermograph was recorded on a photographic film from which it was limited by the long
scanning time. a practical solution to this problem is the use of isotherms. Differences between
the various gray tones are determined accurately by means of a thermal band or isotherm. In
modern thermographic equipment, temperature measurement is improved by providing two
simultaneous isotherm functions.
Analog analysis medicalThermo graphy:
With thermo vision 780M, there are many possibilities of analog analysis of the gray tone images
including the following (i) isotherm function (ii) lever analysis (iii) sample are a selector and
thermal profile analysis.
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Digital analysis of medical Thermography:
In medical fields where complex image patterns are regular occurrence, computers offer new
opportunities for more efficient and objective reasons. First, it can be used to determine
numerous parameters from the image itself, highest and average temperature or differences
between none region and another or area as various temperature contours or geometric centroids
or skewness and so on.
SOFIA
SOFIA is a general image processing program which can be used in nearly all
applications written in FORTRAN IV, it is specially designed to operate with digital data in
OSCAR (Off-line: system for computer Access and Recording)
Lasers
Laser
The light emitted from an ordinary light source is incoherent, because the
radiation emitted from different atoms do not have definite phase relationship with each other.
For interference of light coherent sources are required. Two independent sources cannot act as
coherent sources. For experimental purposes, from a single source, two coherent sources are
obtained. In recent years certain highly coherent sources were developed namely LASER. The
word LASER is an acronym for Light Amplification by Stimulated Emission of Radiation. The
difference between ordinary light and LASER beam is pictorially depicted as follows:
Characteristics of LASER:
The LASER beam is
1. Monochromatic
2. Highly coherent with waves exactly in phase with each other.
3. Doesnt diverge.
4. Extremely intense.
Spontaneous and Stimulated radiation:
An atom may undergo transition between two energy states E
1
and E
2
if it emits or
absorbs a photon of the appropriate energy E
1
-E
2
=h.
In a system of thermal equilibrium the number of atoms in the ground state(N
1
) is
greater than the number of atoms in the excited state(N
2
).This is called Normal population.
Consider a sample of free atoms, some of which are in the ground state with energy E
1
and some
in the excited state with energy E
2
. If the photons of energy E
1
-E
2
=h are incident on the sample,
the photons can interact with the atoms in the ground state and are taken to excited state. This is
called Stimulated or Induced absorption. The process by which the atoms in the ground state are
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taken to the excited state is known as pumping. If the atoms are taken to the higher energy levels
with the help of light it is called Optical pumping. If the atoms in the ground state are pumped to
the excited state by means of external agency, the number of atoms in the excited state(N
2
)
becomes greater than the number of atoms in the ground state(N
1
) then this condition is called
population inversion. The lifetime of the atoms in the excited state is normally 10
-8
seconds.
Some of the excited energy levels have greater life times for atoms (10
-3
seconds). These levels
are called as Metastable state.
If the excited energy level is an ordinary level the excited atoms return to a lower or
ground energy state immediately without the help off any external energy. During this transition
a photon of energy E1-E
2
=h is emitted. This is called spontaneous emission. If the excited state
is a metastable state, the atoms stray for some time in these level and then are brought to a lower
level by the help of the photons of energy E
1
-E
2
=h. During this process a photon of energy E
1
-
E
2
=h is emitted. This is known as Stimulated radiation and the photon produced is called as
stimulated photon or secondary photon. The secondary photon is always in phase with the
stimulating photon. These photons in turn stimulate further emission of photons and hence this
results in a chain reaction. This is called laser action and by this action all the emitted photons
having same energy and same frequency and also in phase with each other. Hence a highly
monochromatic and perfectly coherent intense radiation is obtained.
Conditions to achieve LASER action:
- There must be inverted population.
- The excited state must be a metastable state.
- The emitted photon must stimulate further emission.
This is achieved by the use of the reflecting mirrors at the ends of the system.
Absorbing Energy
Consider the illustration from the previous page. Although more modern views of the atom do
not depict discrete orbits for the electrons, it can be useful to think of these orbits as the
different energy levels of the atom. In other words, if we apply some heat to an atom, we might
expect that some of the electrons in the lower-energy orbitals would transition to higher-energy
orbitals farther away from the nucleus.
Absorption of energy:
An atom absorbs energy in the form of heat, light, or
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electricity. Electrons may move from a lower-energy
orbit to a higher-energy orbit.
This is a highly simplified view of things, but it actually reflects the core idea of how atoms
work in terms of lasers.
Once an electron moves to a higher-energy orbit, it eventually wants to return to the ground state.
When it does, it releases its energy as a photon -- a particle of light. You see atoms releasing
energy as photons all the time. For example, when the heating element in a toaster turns bright
red, the red color is caused by atoms, excited by heat, releasing red photons. When you see a
picture on a TV screen, what you are seeing is phosphor atoms, excited by high-speed electrons,
emitting different colors of light. Anything that produces light -- fluorescent lights, gas lanterns,
incandescent bulbs -- does it through the action of electrons changing orbits and releasing
photons.
The Basics of an Atom
There are only about 100 different kinds of atoms in the entire universe. Everything we
see is made up of these 100 atoms in an unlimited number of combinations. How these atoms are
arranged and bonded together determines whether the atoms make up a cup of water, a piece of
metal, or the fizz that comes out of your soda can!
Atoms are constantly in motion. They continuously vibrate, move and rotate. Even the atoms that
make up the chairs that we sit in are moving around. Solids are actually in motion! Atoms can be
in different states of excitation. In other words, they can have different energies. If we apply a
lot of energy to an atom, it can leave what is called the ground-state energy level and go to an
excited level. The level of excitation depends on the amount of energy that is applied to the atom
via heat, light, or electricity.
The Laser/Atom Connection
A laser is a device that controls the way that energized atoms release photons. "Laser" is an
acronym for light amplification by stimulated emission of radiation, which describes very
succinctly how a laser works.
Although there are many types of lasers, all have certain essential features. In a laser, the lasing
medium is pumped to get the atoms into an excited state. Typically, very intense flashes of
light or electrical discharges pump the lasing medium and create a large collection of excited-
state atoms (atoms with higher-energy electrons). It is necessary to have a large collection of
atoms in the excited state for the laser to work efficiently. In general, the atoms are excited to a
level that is two or three levels above the ground state. This increases the degree of population
inversion. The population inversion is the number of atoms in the excited state versus the
number in ground state.
Once the lasing medium is pumped, it contains a collection of atoms with some electrons sitting
in excited levels. The excited electrons have energies greater than the more relaxed electrons.
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Just as the electron absorbed some amount of energy to reach this excited level, it can also
release this energy. As the figure below illustrates, the electron can simply relax, and in turn rid
itself of some energy. This emitted energy comes in the form of photons (light energy). The
photon emitted has a very specific wavelength (color) that depends on the state of the electron's
energy when the photon is released. Two identical atoms with electrons in identical states will
release photons with
Ruby LASER:
The Ruby laser was first developed by T.Maiman in 1960. It consists of a single
crystal of ruby rod of dimensions 10cm and 0.8cm. A ruby is a crystal of aluminium oxide Al
2
O
3
in which some of aluminium ions (Al
3+
) are replaced by chromium ions (Cr
3+
). The opposite
ends of the ruby rod are made flat and parallel, one end is fully silvered and the other end is
partially silvered. The ruby rod is surrounded by a helical Xenon flash tube which provides the
pumping light to raise the chromium ions to upper energy level. In the Xenon flash tube each
flash lasts several milliseconds and in each flash a few thousand joules of energy is consumed.
In normal state most of the chromium ions are in the ground state E
1
. When the ruby rod is
irradiated by a flash of light 5500 radiation (green colour) photons are absorbed by the
chromium ions which are pumped to the excited state E
3
. The excited ion gives up part of its
energy to the crystal lattice and decay without giving any radiation to the metastable state E
2
.
Since the state E
2
has a much longer lifetime (10
-3
seconds) the number of ions on this state goes
on increasing. Thus population inversion is achieved between the states
E
2
and E
1
. When the excited ion from the metastable state E
2
drops down spontaneously to the
ground state E
1
it emits a photon of wavelength 6943.
This photon travels through the ruby rod and is reflected back and forth by the silvered ends until
it stimulates other excited ion and causes it to emit a fresh photon in phase with stimulating
photon. Thus the reflections will amount to the additional stimulated emission, the so-called
Amplification by Stimulated emission. This stimulated emission is the LASER transition. Finally
a pulse of red light of wavelength 6943 emerges through the partially silvered end of the
crystal.
Ruby Lasers
A ruby laser consists of a flash tube (like you would have on a camera), a ruby rod and two
mirrors (one half-silvered). The ruby rod is the lasing medium and the flash tube pumps it.
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1. The laser in its non-lasing state
2. The flash tube fires and injects light into the ruby rod.
The light excites atoms in the ruby.
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3. Some of these atoms emit photons.
4. Some of these photons run in a direction parallel to the
ruby's axis, so they bounce back and forth off the
mirrors. As they pass through the crystal, they stimulate
emission in other atoms.
5. Monochromatic, single-phase, columnated light leaves
the ruby through the half-silvered mirror -- laser light!
Helium Neon LASER:
A continuous and intense laser beam can be produced with the help of gas lasers.
A simplified diagram showing basic features of a He-Ne gas laser is as follows:
He-Ne laser system consists of a quartz discharge tube containing helium and
neon in the ratio of 1:4 at a total pressure about 1mm of Hg. One end of the tube is fitted with a
perfectly reflecting mirror and the other end with partially reflecting mirror. A powerful radio
frequency generator is used to produce discharge in the gas, so that the helium atoms are excited
to a higher energy level.
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When an electric discharge passes through the gas, the electron in the discharge tube
collide with He and Ne atoms and excite them to metastable states of energy 20.61eV and
20.66eV respectively above the ground level. Some of the excited helium atoms transfer their
energy to unexcited Ne atoms by collision. Thus He atom helps in achieving a population
inversion in Ne atoms. When an excited Ne atom drops down spontaneously from the metastable
state at 20.66eV to lower energy state at 18.7eV it emits a 6328
Photon in the visible region. This photon traveling through the mixture of the gas is reflected
back and forth by the reflector ends, until it stimulates an excited neon atom and causes it to emit
a fresh 6328 photon I phase with the stimulating photon. This stimulated transition from
20.66eV to 18.7eV is the laser transition. The o/p radiation atoms drop down from the 1837eV to
lower state E
1
through spontaneous emission emitting incoherent light. From this level E
1
the Ne
atoms are brought to the ground state through collision with the walls of the tube. Hence the final
transition is radiationless.
Laser Light
Laser light is very different from normal light. Laser light has the following properties:
- The light released is monochromatic. It contains one specific wavelength of light (one
specific color). The wavelength of light is determined by the amount of energy released
when the electron drops to a lower orbit.
- The light released is coherent. It is organized -- each photon moves in step with the
others. This means that all of the photons have wave fronts that launch in unison.
- The light is very directional. A laser light has a very tight beam and is very strong and
concentrated. A flashlight, on the other hand, releases light in many directions, and the
light is very weak and diffuse.
To make these three properties occur takes something called stimulated emission. This does not
occur in your ordinary flashlight -- in a flashlight, all of the atoms release their photons
randomly. In stimulated emission, photon emission is organized.
The photon that any atom releases has a certain wavelength that is dependent on the energy
difference between the excited state and the ground state. If this photon (possessing a certain
energy and phase) should encounter another atom that has an electron in the same excited state,
stimulated emission can occur. The first photon can stimulate or induce atomic emission such
that the subsequent emitted photon (from the second atom) vibrates with the same frequency and
direction as the incoming photon.
The other key to a laser is a pair of mirrors, one at each end of the lasing medium. Photons, with
a very specific wavelength and phase, reflect off the mirrors to travel back and forth through the
lasing medium. In the process, they stimulate other electrons to make the downward energy jump
and can cause the emission of more photons of the same wavelength and phase. A cascade effect
occurs, and soon we have propagated many, many photons of the same wavelength and phase.
The mirror at one end of the laser is "half-silvered," meaning it reflects some light and lets some
light through. The light that makes it through is the laser light.
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You can see all of these components in the figures on the following page, which illustrate how a
simple ruby laser works.
Types of Lasers
There are many different types of lasers. The laser medium can be a solid, gas, liquid or
semiconductor. Lasers are commonly designated by the type of lasing material employed:
- Solid-state lasers have lasing material distributed in a solid matrix (such as the ruby or
neodymium:yttrium-aluminum garnet "Yag" lasers). The neodymium-Yag laser emits
infrared light at 1,064 nanometers (nm). A nanometer is 1x10
-9
meters.
- Gas lasers (helium and helium-neon, HeNe, are the most common gas lasers) have a
primary output of visible red light. CO2 lasers emit energy in the far-infrared, and are
used for cutting hard materials.
- Excimer lasers (the name is derived from the terms excited and dimers) use reactive
gases, such as chlorine and fluorine, mixed with inert gases such as argon, krypton or
xenon. When electrically stimulated, a pseudo molecule (dimer) is produced. When lased,
the dimer produces light in the ultraviolet range.
- Dye lasers use complex organic dyes, such as rhodamine 6G, in liquid solution or
suspension as lasing media. They are tunable over a broad range of wavelengths.
- Semiconductor lasers, sometimes called diode lasers, are not solid-state lasers. These
electronic devices are generally very small and use low power. They may be built into
larger arrays, such as the writing source in some laser printers or CD players.
A ruby laser (depicted earlier) is a solid-state laser and emits at a wavelength of 694 nm. Other
lasing mediums can be selected based on the desired emission wavelength (see table below),
power needed, and pulse duration. Some lasers are very powerful, such as the CO2 laser, which
can cut through steel. The reason that the CO2 laser is so dangerous is because it emits laser light
in the infrared and microwave region of the spectrum. Infrared radiation is heat, and this laser
basically melts through whatever it is focused upon.
Other lasers, such as diode lasers, are very weak and are used in todays pocket laser pointers.
These lasers typically emit a red beam of light that has a wavelength between 630 nm and 680
nm. Lasers are utilized in industry and research to do many things, including using intense laser
light to excite other molecules to observe what happens to them.
Here are some typical lasers and their emission wavelengths:
Laser Type Wavelength (nm)
Argon fluoride (UV) 193
Krypton fluoride (UV) 248
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Xenon chloride (UV) 308
Nitrogen (UV) 337
Argon (blue) 488
Argon (green) 514
Helium neon (green) 543
Helium neon (red) 633
Rhodamine 6G dye (tunable) 570-650
Ruby (CrAlO
3
) (red) 694
Nd:Yag (NIR) 1064
Carbon dioxide (FIR) 10600
Medical Applications of LASER:
- Micro surgery has become possible due to narrow spread angle of the laser beam.
- It can be used in the treatment of kidney stone, tumour, cutting and sealing small blood
vessels in brain surgery and retina detachment.
- The laser beam is used in endoscopy.
- It can also be used for the treatment of human and animal cancer.
MASER:
The term MASER stands for Microwave Amplification by Stimulated Emission
of Radiation. The working of maser is similar to that of laser. The maser action is based on the
principle of Population Inversion followed by Stimulated emission. In maser the emitted photon
during the transition from the metastable state belongs to the microwave frequencies. The
paramagnetic ions are used as maser materials. Practical maser materials are often chromium or
gadolium ions doped as impurities in ionic crystals. Ammonia gas is also a maser material.
Maser provides a very strong tool for analysis in molecular spectroscopy.
LASER SURGERY
Laser surgery, pioneered by Russia, is surgery using a laser (instead of a scalpel)
to cut tissue.
Examples include the use of a laser scalpel in otherwise conventional surgery, and soft
tissue laser surgery, in which the laser beam vaporizes soft tissues with high water
content. Laser resurfacing is a technique in which molecular bonds of a material are
dissolved by a laser. Laser surgery is commonly used on the eye. Techniques used
include LASIK, which is used to correct near and far-sightedness in vision, and
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phorefractive keratectomy, a procedure which permanently reshapes the cornea using
an excimer laser to remove a small amount of tissue.
Types of surgical lasers include carbon-dioxide, argon, Nd:YAG, and KTP.
Eye surgery
Various types of laser surgery are used to treat refractive error:
LASIK,in which a knife is used to cut a flap in the cornea, and a laser is used to reshape
the layers underneath, to treat refractive error INTRALASIK, a variant in which
the flap is also cut with a laser
Photorefractive keratectomy(PRK, LASEK), in which the cornea is reshaped without
first cutting a flap Laser thermal keratoplasty, in which a ring of concentric burns is
made in the cornea, which cause its surface to steepen, allowing better near vision
Laproscopic surgery
Laparoscopic surgery, also called minimally invasive surgery (MIS), bandaid surgery,
or keyhole surgery, is a modern surgical technique in which operations in
the abdomen are performed through small incisions (usually 0.51.5 cm) as opposed to
the larger incisions needed in laparotomy.Keyhole surgery makes use of images
displayed on TV monitors to magnify the surgical elements. Laparoscopic surgery
includes operations within the abdominal or pelvic cavities, whereas keyhole surgery
performed on the thoracic or chest cavity is called thoracoscopic surgery. Laparoscopic
and thoracoscopic surgery belong to the broader field of endoscopy. The key element in
laparoscopic surgery is the use of a laparoscope. There are two types: (1) a telescopic
rod lens system, that is usually connected to a video camera (single chip or three chip), or
(2) a digital laparoscope where the charge coupled device is placed at the end of the
laparoscope, eliminating the rod lens system.
DIATHERMY:
Diathermy therapy is generally contra-indicated for pacemaker patients.the operation of a
pulse generator subject to the intense fields of energy involved in diathermy cannot be predicted;
reversion to fixed rate pacing is likely, to copmplete inhibition is possible. Although damage to
either pulse generator circuitry or cardiac tissue is highly improbable, it cannot be positively
ruled out. If diathermy therapy must be used, it should be applied away from the immediate
vicinity of the pulse generator/ lead system.
INTRODUCTION:
Operation theatre equipment are very useful both diagnostically and therapeutically. they
are mainly useful for monitoring and treatment purposes. during operation or intensive care or
intensive treatment, the patient's condition is followed carefully by repeated measurement of
many variables, like blood flow velocvity, cardiac output, blood pressure. PH value and so
on.The above variables are also measured and monitored by operation theatre equipment.
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PRINCIPLE OF SURGICAL DIATHERMY:
High frequency currents apart from their usefulness for therapeutic applications can also
be used in the operating rooms for surgical purposes involving cutting and coagulation. The
frequency of currents used in surgical diathermy units is in the range of 1-3MHz in contrast with
much higher frequencies employed in shortwave therapeutic diathermy machines.The evolving
steam bubbles in the tissues at the cutting action is obtained. Similarly during the passage of the
high frequency current through the tissue, the tissue is heated locally. so that the tissue is melted
instantaneously and sealing of the capillary and other blood vessels is taking place. Then the
coagulation of the tissues takes place. The use of high frequency current is to avoid the intense
muscle activity and the electrocution hazard occurs if low frequencies are used.
Surgical diathermy machines depend for their action, the heating effect of electric
current. When high frequency current flows through the sharp edge of a wire loop or point of a
needle into the tissue. There is a high contraction of current at this point. The tissue is heated to
such an extent that cells immediately under the electrode are torn apart by the boiling of the cell
fluid. The indifferent electrode establishes a large area contact with the patient and the RF
current is therefore dispersed so that very little cheat is developed at this electrode. This type of
tissue separation forms the basis of electrosurgical cutting.
Honig (1975) worked out detailed derivation of the significant parameters affecting the
distribution of electro surgical RF power in tissue. He analyzed how electrosurgical RF power is
localized in the vicinity of the cutting electrode. It was shown that the combination of fine wire
electrodes high RF voltage and high cutting speeds are necessary for the confinement of tissue
destruction in electro surgery. These parameters are of great value in micro surgery since
localization of electrosurgical effects would also be accompanied by coagulation and
homeostasis. His analysis supported the supposition that evolving steam bubbles in the tissues at
the surgical tip continuously rupture the tissue and are responsible for cutting mechanism.
Coagulation:
Electrosurgical coagulation of the tissue is caused by the high frequency current flowing
through the tissue and heating it locally so that it coagulates from inside. The coagulation process
is accompanied by a grayish-white discoloration of the tissue that the edge of the electrode. In
contrast to a thermocauter, better coagulation can be achieved by high frequency currents
because it does not cause superficial burning.
Fulguration:
The term fulguration refers to a superficial tissue destruction without affecting deep-seated
tissues. This is obtained by passing sparks from the needle or ball electrode of small diameter to
the tissue. When electrode is held near the tissue without toughing it, spark is produced. This
spark is capable of burning the unwanted portions.
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Desiccation:
The needle point electrodes are stack into the tissue and kept steadily while passing
electric current. This creates a high local increase in heat and drying of tissues is taking place.
This is called desiccation.
Blending:
When the electrode is kept above the skin, an electrical arc is sent. The developed heat
produces wedge shaped narrow cutting of the tissue on the surface. By increasing the current
level, deeper level cutting of the tissues takes place. Normally continuous RF current is used for
cutting.
Hemostasis:
The concurrent use of continuous RF current for cutting and a RF wave burst for
coagulation is called Hemostasis mode.
Electrical Shock
8.1 Introduction:
Electric shock is a traumatic state caused by the passage of electric current can flow
through the human body either accidentally or intentionally. The kind and amount of damage
depends on the intensity, type and duration of the current, the point where the electricity first
touched the body and the path it took through the body. Burns may be superficial or very deep
with widespread tissue death. Severe shock may cause muscle contractions, respiratory paralysis,
unconsciousness and cardiac arrest. A high voltage electric shock may cause sudden muscle
spasm that may through the victim away from the power source with extreme force, resulting in
further injuries, such as fracture. Lightening causes injuries similar to those sustained from a
high voltage electric shock. Electrical currents are administered intentionally in the following
case.
- For measurement of respiration rate by impedance method, a small current at high
frequency is made to flow between the electrodes applied on the surface of the body.
- High currents are also passed through the body for therapeutic and surgical purposes.
- When recording signals like ECG, and EEG, the amplifiers used in the preamplifier stage
may deliver small currents themselves to the patient. These are due to bias currents.
Accidental transmission of electrical current takes place because of defect in the
equipment; excessive leakage and simultaneous use of other equipment on the patient
which may produce potentials on the patient circuit.
8.2 Electric shock hazards:
It is a common experience that the hazards due to electric shock are also
associated with equipment other than that used in hospitals. However, the equipments used in
medical practice have to operate in special environments. Which differ I certain respects from
others. Some such special situations are as follows:
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- A patient may not be usually able to react in the normal way. He/she is either ill,
unconscious anaesthetized or strapped on the operating table. He/she may not be able to
withdraw him/herself from the electrified object, when feeling tingling in his/her skin,
before any danger of electrocution occurs.
- The patient or the operator may not realize that a potential hazard exists. This is because
potential differences are small and high frequency and ionizing radiations are not directly
indicated.
- Considerable neutral protection and barrier to electric current is provided by human skin.
In certain applications of electro medical equipment, the natural resistance of the skin
may be passed. Such situations arise when the tests are carried out on the subject with a
catheter in his/her heart or an large blood vessels.
- Electro medical equipment, example : pacemakers may be used either temporarily or
permanently to support or replace functions of some organs of the human body. The
interruption in the power supply or failure of the permanent injuries or even prove fatal
for the patient.
- Medical instruments are quite often used in conjunction with several other instruments
and equipment. These combinations of high power equipment and extremely sensitive
low signal equipment. Each of these devices may be safe in itself, but can become
dangerous when used in conjunction with others.
- Environmental conditions in the hospitals particularly in the operating theatres cause
explosion or fire hazards due to the presence of anesthetic agents, humidity and cleaning
agents etc.
8.3 Effects due to 50 Hz current passage:
This electric shock can cause unwanted cellular depolarization. This is associated with
muscular contraction, or it may cause cell vaporization and tissue injury. The effect of
commercial frequency currents on the human body should be considered. This assists in
establishing allowable leakage currents for electrical appliances and electric hand tools. Most of
the electrical accidents involve a current pathway through victim from one upper limb to the feet
or to the opposite upper limb. At commercial frequencies, the body acts as a volume conductor.
For commercial frequencies (50 Hz 60 Hz) specific physiological effects due to passage of
current through the body are listed below:
- Type of current range (mA)
- Physiological effect
- Threshold1-5
- Tingling sensation5-8
- Intense or painful sensation
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- Let go 8-20
- Threshold of involuntary muscle contraction paralysis >20.
Respiratory paralysis and heart fibrillation 80-1000, ventricular and heart defibrillation 1,000 to
10,000 sustained myocardial contraction, temporary respiratory paralysis and possible tissue
burns.
Let-go current is the minimum current to produce muscular contraction. For men it is
about 16 mA and for women it is about 10.5 mA.
8.4 Microshock and Macroshock:
8.4.1 Macroshock:
A physiological response to a current applied to the surface of the body that produces
unwanted or unnecessary stimulation like muscle contractions or tissue injury is called macro
shock. All hospital patients and medical attendants are exposed from defective electric devices
and bio-medical equipment.
8.4.2 Microshock:
A physiological response to a current applied to a surface of the heart that results in
unwanted stimulation like muscle contractions or tissue injury is called microshock. Micro
shock is most often caused when currents in excess of 10 microamperes, flow through an
insulated catheter to the heart. The catheter may be an insulated, conductive-fluid filled tube, or a
solid wire pacemaker cable. The micro shock results because the current density at the heart
become high in the situation depicted there, in which the catheter touches the heart.