MODULE III THERAPEUTIC AND ANALYTIC INSTRUMENTS

3.1.0 To Understand the different types of therapeutic instruments

3.1.1 To State the need of pacemakers
3.1.2 To Classify different types of pacemakers
3.1.3 To Compare the implantable pacemakers and external pacemakers
3.1.4 To Draw the block diagram of a ventricular synchronous demand
pacemaker and to explain its operation.
3.1.5 To State the need of defibrillators.
3.1.6 To describe ac defibrillators and dc defibrillators.
3.1.7 To explain the functions of haemodialysis machine.
3.1.8 To State the use of respirators.
3.1.9 To State the need of ventilator.
3.1.10 To List the different types of diathermy equipments.
3.1.11 To explain the working of short wave diathermy unit
3.1.12 To List the advantages and disadvantages of short wave diathermy
treatment.
3.1.13 To explain the working of Ultrasonic diathermy unit .
3.2.0 To Understand the necessity of blood cell counting
3.2.1 To explain the working of electrical conductivity blood cell counter

PACEMAKERS
Pacemaker is an electrical pulse generator for starting and /or maintaining the normal heartbeat.The
output of the pacemaker is applied externally to the chest or internally to the heart muscle. The
rhythmic beating of the heart is due to the triggering pulses that originate in an area of specialised
tissue in the right atrium of the heart. This area is known as Sino-atrial node. In abnormal situations,
when this natural pacemaker stop to function, become unreliable or the triggering pulse does not
reach the heart muscle because of blocking by the damaged tissues, the natural and normal
synchronising of heart action gets disturbed. This situation shows a decrease in heart rate and
changes in ECG waveforms. By giving external electrical stimulation impulses to the heart muscle,
it is possible to regulate the heart rate. These impulses are given by an electronic instrument called
'pacemaker'. Hence a pacemaker is a device which produces pulses and delivers them to the heart.
3.1.1 To State the need of pacemakers:
1. for the treatment of cardiac rhythm disorders
2. For the treatment of Brady arrhythmias (ventricular rate of less than 60 beats per minute) and
tachy arrhythmias (having a ventricular rate of greater than 100 beats per minute)
3. Any abnormalities in the SA node, AV node and His Purkinje system.
4. In the cases of heart block like AV node block and left-bundle branch block.

3.1.2 To Classify different types of pacemakers

The classification based on the mode of application of stimulus pulses to the heart.
1. External pacemakers – it isused when the heart block is present for a short time. That is during
critical post-operative periods (after a heart surgery) and also during patients cardiac surgery,
2. Internal pacemakers – it is used in cases requiring long term pacing because of permanent
damage that prevents normal self-triggering of the heart. Here the pacemaker is implanted in the
body below the right or left clavicle (collar bone). The patient is able to move about freely. Internal
leads connect to electrodes that are directly in contact with the inside of the right ventricle or the
surface of the myocardium.
The internal pacemakers are further divided into
a) fixed Rate Units Pacemakers or asynchronous pacemakers
These are used for patients having permanent block. It operates in fixed rate of heart beats per
minutes. The rate can be varied externally from 70 to 95 beats per minute by magnetically actuating
built in relay in hospitals. Once it is fixed, it can be varied only at the hospitals.
b) Demand Pace Makers
These pacemakers have gradually almost replaced the fixed rate pacemakers because they
avoid competition between the heart’s natural rhythm and the pacemaker rhythm. The
demand unit functions only when the R-R intervals of the natural rhythm exceed a pre-set
limit
1.Atrial triggered pacemaker. The pacemaker detects the atrial de-polarization and starts the
pulse forming circuits after a delay so that the impulse to the ventricles is delivered after a suitable
PR interval
2. Ventricular Inhibited: The ventricular inhibited type (R wave blocked) pacemaker is meant
for patients who generally have sinus rhythm with occasional heart block. The circuitry detects R
wave potentials at the electrodes and the pacemaker provides a stimulus to the heart However, in
the case of ventricular activity, the R-wave does not trigger the output circuit of the pacemaker
3. R wave Triggered Pacemaker: The ventricular synchronized demand type (R wave
triggered) pacemaker is meant for patients who are generally in heart block with occasional sinus
rhythm.
4. The Bi-Focal Demand Pace Maker- This pacemaker stimulates both atria and ventricles in
sequence. Thus the pacemaker functions automatically according to patient needs.
3.1.4 To Draw the block diagram of a ventricular synchronous demand
pacemaker and to explain its operation.

Ventricular synchronous demand pacemaker

• It allows heart to pace at its normal rhythm when it is able to.
• If heart fails or R wave is missing, the pacemaker will turn on and provide pulses.
• Hence it is called demand pacemaker.
• Further there is a sensor to detect the patient’s body activity and accordingly the
pacemaker automatically increase or decrease its rate.
• It is used in case of occasional rhythm failure in SA note.
• it uses feedback to read R wave and triggers ventricles with some delay.
• It Senses the natural operation that is R wave generated by SA node. delay between
two adjacent pulses increases or decreases, it takes the control and generates trigger
pulses to the ventricle . Same electrode is used for sending trigger signal to the heart
and also for sensing R wave from SA node.
• It has two functions- pacing and sensing
Electrode - While sensing it detects the R-wave (QRS) through the electrode. During pacing,
electrode gives trigger pulses to the heart.
Filter - filters 30 HZ R wave alone.
QRS amplifier - amplifies this R-wave to the required level.
Threshold detector - has 1 to 2 mV sensitivity to detect R wave which has typical amplitude of 1-
30mv.
Refractory period T1 circuit- is a delay circuit. It is necessary because after action potential initiates
(muscle contraction), cardiac muscle can’t initiate next action potential or muscle contraction for
some time. The time period is called refractory period.
Free running oscillator - operates at T2 period and it is the rate of the pacemaker at which heart
beats.
Output driver - amplifies these signal to suitable amplitude and keeps the pulse for a width of T3 to
initiate proper heart contraction.
Defibrillator protection circuit - protects pacemaker from high electric shock coming from defibrillator
if it is used for the patient.

Advantages
1. To avoid ventricular fibrillation
2. If R wave at low amplitude, it amplifies
3. If R wave is at low or high frequency, it corrects it to normal value of 70/minute so that heart
beats at 70/minute
Disadvantage
Atrial and ventricular contraction not synchronized
3.1.3 To Compare the implantable pacemakers and external pacemakers
External pacemaker Internal pacemaker
The pacemaker is placed outside the body. It The pacemaker is small and is surgically
may be in the form of wrist watch or in the implanted beneath the skin near the chest or
pocket, from that one wire will go into the heart abdomen. Output leads are connected directly
through the vein to the heart muscle.

The electrodes are called endocardiac The electrodes are called myocardiac
electrodes and are applied to the heart by electrodes and are in contact with the outer will
means of an electrode catheter with electrode's of the myocardium (heart muscle)
tip situated in the top of the right ventricle.
These are in contact with the inner surface of
the heart chamber.
It does not necessitate the open chest It requires an open chest minor surgery to
surgery place the circuit.

The battery can be easily replaced and any The battery can be replaced only by minor
defect or adjustment in the circuit can be easily surgery. Further any defect or adjustment in
attended without getting any help from a the circuit cannot be easily attended. Doctor's
medical doctor. help is necessary to rectify the defect in the
circuit.

During placement, swelling and pain do not During placement swelling and pain arise
arise due to minimum foreign body due to foreign body reaction.

Here there is no safety for the pacemaker Here there is a hundred percent safety, for
particularly in the case of children carrying the the circuit from the external disturbances.
pacemaker
 Mostly these are used for temporary heart Mostly these are used for permanent heart
irregularities damages

Defibrillator
A defibrillator is a device that delivers electric shock to the heart muscle undergoing a fatal
arrhythmia. (Ventricular or atrial fibrillation). Fibrillation is asynchronous contraction of heart muscle.
Defibrillator gives sustained myocardial depolarization.S udden cardiac arrest can be treated using
defibrillator.It delivers 1 to 60A of 50Hz current across the patient’s chest for 1 to 5 ms and also with
a range of 50 v to 6000 v shock voltage having an excitation energy of 15 to 400 Joules.
. 3.1.5 To State the need of defibrillators.
• To deliver electric shock to the heart muscle undergoing a fatal arrhythmia. (Ventricular or
atrial fibrillation)
• Sudden cardiac arrest can be treated using defibrillator
• Defibrillator gives sustained myocardial depolarization

TYPES OF DEFIBRILLATORS
Based on the electrode placement defibrillators can be classified into two types: 1. internal
defibrillators. 2. External defibrillators. Based on the nature of the voltage applied, the defibrillators
can be classified into two types: 1. AC defibrillators 2. DC defibrillators
Compare AC and DC defibrillators
AC defibrillators DC defibrillators
Simple and easy to operate Simple and safe to operate
Large currents are required for external High energy shock is given by
defibrillators discharging a capacitor
This current causes violent No desirable side effects.
Produces normal heart beat Produces normal heart beat effectively,
Occasional burning of the skin under electrodes. No skin burns.
Only an alternating wave is used to deliver the Different voltage waveforms can be selected
shock. to deliver the shock.
Shock cannot be synchronized with ECG to correct Shock can be synchronised with ECG to
fibrillation at the right time. correct fibrillation at the right time.
Not very effective Very effective.
It produces atrial fibrillation while arresting No such effects are observed.
ventricular fibrillation.
The technician administering the shock is unsafe. The technician administering the shock is
safe.
3.1.6 To describe ac defibrillators and dc defibrillators.
AC Defibrillator
In AC defibrillation, a shock of 50 Hz a.c frequency is applied to the chest for a time of 0.25 to 1
second through electrodes.

AC defibrillator consists of a step-up transformer with primary and secondary winding, and two
switches.
A.C supply is given through switches and fuse to primary winding of the transformer.
The timing circuit is connected with switch.
A resistive and a simple capacitor network or monostable multivibrator forms the timing circuit. It is
triggered with a foot switch or a push button switch.
Various tapping are available along the secondary winding. They are connected to the electrodes
that delivers electric shock to the heart of the patient. Voltage value ranging between 250 V to 750
V is applied for AC external defibrillation.
For safety reasons, secondary coil should be isolated from earth to avoid shock.

DC Defibrillator
DC defibrillator does not produce side effects and produces normal heartbeat.
Ventricular fibrillation is avoided when high-energy shock is passed through discharging capacitor
that is exposed to heart or chest of the patient.
 • DC defibrillator consists of auto transformer T1 that acts as primary of the high voltage
transformer T2.
• A diode rectifier rectifies the output voltage from T2.
• It is connected to vacuum type-high voltage over switch.
• At position A, switch is connected to one end of the capacitor.
• When connected in this position capacitor charges to a voltage.
• A foot switch present on the handle of the electrode is used to deliver shock to the patient.
• Now the high voltage switch changes it position to B that makes the capacitor to discharge
to the heart through electrodes.
• To slow down the discharge from the capacitor an inductor L is placed in one of the electrode
lead. This L induces a counter voltage that reduces the capacitor discharge value.
3.1.7 To explain the functions of haemodialysis machine.
DIALYSIS :
The function of the kidney is to remove waste products from the blood plasma, to Regulate the
composition of blood plasma and to maintain constant blood pressure. During the renal damage,
the kidneys will not function properly and the creatinine and urea (nitrogen compound) level in the
urine is reduced and leads to accumulation of toxic substances in the body. When the kidney failure
is diagnosed, artificial kidney (dialyser) may be intermittently employed
The functions of a Dialysis Machine with diagram
1. Reducing the accumulation of waste products and water in the body.
2. Maintains the normal pH value of the blood.
3. Maintains/regulates constant blood pressure.
4. Maintains the creatinine and urea levels in urine.
5. Maintains/regulates blood sodium, potassium, sulphates etc in the blood
6. Removes the toxic substances from the body.
x

HaemoDialysis Machine
Dialyzer Working principle

Hemodialysis is a process that involves the removal of toxic chemical substances from the blood by
passing the blood through tubes surrounded by semi-permeable membranes.
For short term use, a double lumen catheter is inserted into the femoral vein and for long term use,
an arterio~venous shunt which is a permanent connection between an artery and a vein is inserted
below the skin in the hand by a minor operation
• The arterio-venous shunt is opened and connected to the dialyser.
• Using a blood pump the blood is pumped into a number of planar sheets of cellophane
which are pressed together in a frame.
• Cellophane sheets are semipermeable.
• Blood flows in alternate spaces and the dialysate flows in the others as shown in the
Figure.
• The dialysate is an electrolyte;
• Through the cellophane sheets, urea, creatinine, uric acid and phosphates are diffused
from blood to dialysate.
• There is a blood leak detector to detect break in membrane.
• Further there are pressure monitoring meters at the input and output.
• A thermostatic control is provided to maintain the blood at 37C.
• The blood is circulated continuously for 3 to 6 hours in the hemodialysis machine.

Respirators.
Exchange of gases in biological process is known as respiration. When a patient is incapable of
respiration by natural process, mechanical assistance must be provided. This provides sufficient
oxygen to the organs of the body and reduces the levels of carbon dioxide. Respirators may either
provide the entire ventilation or assist respiratory activity. A simple respirator consists of a
reciprocating pump operated by an electric motor. The pump draws air from the atmosphere and
pumps the air into the lungs. Later the air is taken out of the lungs with a small negative pressure.
The frequency of operation is determined by the speed of the motor and the coupling with the pump.
A simple respirator is suitable only for total external ventilation.
3.1.8 To State the use of respirators
When a patient is incapable of respiration by natural process, mechanical assistance must be
provided. This is done by respirators.
This provides sufficient oxygen to the organs of the body and reduces the levels of carbon dioxide.
Respirators may either provide the entire ventilation or assist respiratory activity.

There are two types respirators

1 synchronous respirator -in this electronic techniques have to be used to match the external
ventilatory force with natural respiratory effort of the patient. The synchronised respirator must have
a provision for automatic desynchronization when the natural rate is too low.

2 Asynchronised respirator simply pushes air to the lungs and takes the air out without checking the
patients effort to inhale and exhale.
Classification of Ventilators according to Pressure Cycling And Volume
Cycling.
. During inspiration, air or other gaseous mixture is pumped into the lungs. During expiration, the
pressure is made to cease and air is taken from the lungs. This cycle is controlled by different ways.
Accordingly we have the following types of ventilators :

1. Pressure-cycled ventilator.
The pressure-cycled ventilator, the inspiration is stopped when the gaseous mixture or air pumped
into the lungs reaches a predetermined pressure. The pressure limit can be set during inspiration
or expiration or both. These are simple in construction and reliable in operation. The benefit is a
decreased risk of lung damage from high respiratory pressures.
2. Volume-cycled ventilator.
in the volume-cycled ventilator, a predetermined volume of gas is given to the patient for each
breath. During inspiration the constant volume of air is sent to the lungs..
3. Servo-controlled ventilator.
by applying a pressure to a chamber containing known volume. However, these sometimes do not
give the desired ventilation. In servo controlled ventilator, modern electronic circuits are used to
regulate inspiration and expiration process. The feedback and control techniques are used to
achieve this. It uses both volume and pressure control and has got the advantage of both.
All the above ventillator may work in three modes
Controlled mode – breathing controlled by automatic timing system. Used for patients who cannot
breath
Assisted mode – patients spontaneous attempts to breath in, causes the ventilator on during
inspiration. Used in patients who has difficulty in breathing
Control assisted – patients controls his own breathing but when he fails, the control mode is able to
take over from him

DIATHERMY

Diathermy means 'through heating' or producing deep heating. It directly heats the tissues of the
body. Applying heat to a particular area of the body increases the temperature of the tissues and
hence blood flow is increased in that area. Conventional methods like hot towel, infra red lamp
electric heat pads etc discomfort and skin burn. In diathermy, the body becomes a part of the
electrical circuit and heat is produced with in the body. The advantage of the diathermy is that the
treatment can be controlled precisely by careful placing the electrodes. It also permits the
localization of the heat to the region to be treated. The heating of the tissue is done by radio
frequency alternating current.

3.1.10 To List the different types of diathermy equipments.

1. Shortwave diathermy
2. Microwave diathermy
3. Ultrasound Diathermy
4. Surgical Diathermy
3.1.11 To explain the working of short wave diathermy unit
The block diagram of short wave diathermy is given below

• In short wave diathermy heating of the tissues is carried out at a high frequency of 27.12
MHz, and a wavelength of 11m.
• The output power is 500 W.
• The high energy power supply is given to the RF oscillator.
• RF oscillator produce high power short wave signals and the output of the RF oscillation is
applied to a pair of patient electrodes with the help of Monitor control panel.
• The Monitor control panel can adjust the frequencies, wavelength and the output power to
prevent excessive heating of tissue and burning.
• The isolation transformer keeps the patient circuit in resonance with the input circuit.
• It isolates the RF oscillator from the electrodes and prevents unwanted frequency variations
in the oscillators.
• The RF Energy heats the tissues and promotes the heating of injured tissues and
inflammations. The patient electrodes or pads are not directly in contact with the skin.
• Usually, layers of towels are interposed between the metal and the surface of the body.

Different methods of applying electrodes in short wave diathermy

There are two techniques of applying heat to the body. They are Capacitor method or condenser
method and inductive method or lnductothermy

(i) Capacitor method or condenser method

in the capacitor
method, the pads form
capacitor ‘ plates and
the body tissues
between the pads acts
as a dielectric. When
the RF current is
applied to the pads, the
dielectric loss of the
capacitor thats is the
body between the
plates, produces heat.
(ii) inductive method or lnductothermy.

In the inductive method, a flexible cable is coiled around the arm or knee or any other portion of the
patients body, where plate electrodes are inconvenient to use. When RF current is passed through
the cable, deep heating in the tissue results. This is due to the electrostatic field set up between the
ends. the superficial tissue are heated by eddy current set up by the magnetic field around the cable.
This method is used in body joints where capacitor plates cant be placed. The RF waves applied
can be given continuously or pulsed.

3.1.12 To List the advantages and disadvantages of short wave diathermy treatment
ADVANTAGES AND DISADVANTAGES OF SHORT WAVE DIATHERMY
1. The subject's body becomes. a part of the electrical circuit and the heat is produced within the
body and not transferred through the skin.

2. The treatment can be controlled precisely.

3. Careful placement of the electrodes permits localization of the heat to the region that has to be
treated.

4. The amount of heat can be closely adjusted by means of circuit parameters.

5. No discomfort is caused to the subject.

6. The current being alternating, it is possible to pass t currents of a much greater intensity to
produce direct heating in the tissues similar.

7. The RF energy used heats the tissues and promotes healing of injured tissues and inflammations.
Disadvantages

1. frequency Tuning must be carefully carried out at the beginning of the treatment and continuously
monitored during the treatment; There is a possibility of the tuning getting affected due to
unavoidable but involuntary movements of the patients and the resultant change of dosage of heat.

2. There is no indication of the amount of converted and absorbed heat within the body tissues.

3. The intensity of the treatment is dependent on the subjective sensation of warmth felt by the
patient.

4. A severe limitation is that in SW diathermy, continuous high frequency radio waves are directed
to the patients body, and if a high enough output of energy is sustained for even a brief time, they
can cause burns.

3.1.13 To explain the working of Ultrasonic diathermy unit

• Ultrasonics are used for therapeutic purposes in the same manner as a short-wave
diathermy machine is used.
• The heating effect in this case is produced because of the ultrasonic energy absorption
property of the tissues.
• . The effect of ultrasonics on the tissues is thus a high-speed vibration or micro-massage.
Massage in physical medicine has been used in the treatment of soft tissue for centuries.
• The thermal effects of ultrasound are dependent on the amount of energy absorbed, the
length of time of the ultrasound application and the frequency of the ultrasound generator.
• The electrical power required in most of the applications is usually less.
• Ultrasonic generators are constructed on the piezo-electric effect.
• A high-frequency alternating current (e. g., 0.75-3.0 MHz) is applied to a crystal whose
acoustic vibration causes the mechanical vibration of a transducer head, which itself is
located directly in front of the crystal.
• These mechanical vibrations then pass through a metal cap and into the body tissue
through a coupling medium.
• This ultra sound energy vibrates the tissue and heats the tissue.

3.2.0 To Understand the necessity of blood cell counting

A blood count test provides a variety of information about your health.
.It gives the count of RBCs,WBCs,Platelets etc,
 A low red blood cell count could mean you have anemia, while a low white blood cell count could
signify neutropenia, a condition that puts you at a higher risk for infection.

An abnormal platelet count may indicate you have a blood clotting disorder

3.2.1 To explain the working of electrical conductivity blood cell counter

Working
• A dilute sample is drawn through a small orfice by a suction pump.
• The electrodes are placed such that one is surrounding chamber and other in suctioned
blood.
• The electrodes are attached as arms of the conductivity bridge.
• Before suction.Resistance= R.After suctioning,Resistance=R+∆R.
• Hence Vout is proportional to ∆R.
• Conductivity meter gives output as impulses.
• Counter gives total number of RBCs and WBCs per litre.