OEC 754 MEDICAL ELECTRONICS

UNIT III ASSIST DEVICES 9

Cardiac pacemakers, DC Defibrillator, Dialyzers, Ventilators, Magnetic Resonance Imaging Systems,
Ultrasonic Imaging Systems.

Cardiac Pacemakers:
➢ Pacemaker is an electrical pulse generator for starting and/or maintaining the normal heart beat.
The output of Pacemaker is applied either externally to the chest or internally to the heart muscle.
➢ In case of cardiac standstill the use of pacemaker is temporary just long enough to start a normal
heart rate. In long term pacing pacemaker is surgically implanted in the body and its electrodes are
in direct contact with heart.
➢ In cardiac diseases where the ventricular rate is too low it can be increased to normal rate by using
pacemaker.
Energy requirements to excite heart muscle:
➢ The heart muscle can be stimulated with an electric shock. The minimum energy required to excite
heart muscle is 10µJ.
➢ For better stimulation and safety purposes 100µJ pulse energy is applied on heart muscle. During
ventricular fibrillation heart muscle contracts so rapidly and irregularly. The pulse to space ratio
1:10000
➢ The concentration of sodium ions inside the cell becomes much lower than outside. Since the sodium
ions are positive, the outside of the cell is more positive than inside.
➢ To balance the electric charge, potassium ions which are positive enters the cell causing a higher
concentration of potassium on inside than on outside.

Fig: Pacemaker pulses

➢ The negatively going pulses to avoid ionization of muscles. Pulse repetition rate is usually 70
pulses/min but many pacemakers are adjustable in the range of 50-150pulses/min. The circulation
of each pulse is between 1to2ms.
Methods of stimulation:
➢ There are two types of stimulation (i) Internal stimulation (ii) External stimulation
(i)Internal stimulation: It is employed for long term pacing because of permanent damage. Electrodes in the
form of fine wires of Teflon coated stainless steel. The current range is 2-5mA.Bipolar and Unipolar electrode
are used.
➢ Bipolar electrode: There are stimulating electrode and contact electrode which serves as a return
path for current to pacemaker.
➢ Unipolar electrode: There is only stimulating electrode and the return path for current to pacemaker
is made through body fluids.

(ii) External stimulation: It is employed to restart the normal rate of heart in case of cardiac stand still. The
paddle shaped electrodes are applied on the surface of chest current in the range of 20-150mA
Based on the placement of pacemaker there are two types
(i)External pacemaker
(ii)Implanted (Internal pacemaker)

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Table: External pacemaker Vs Internal Pacemaker
External pacemaker Implanted (Internal) pacemaker
The pacemaker is placed outside the body. It may be in
The pacemaker is surgically implanted beneath the skin
the form of wrist watch or in packet from one wire go in
near the chest
to heart through the vein.
The electrodes are called endocardiac electrode and The electrodes are called myocardiac electrode and are
are applied to heart in contact with heart muscle.

It does not require the open chest surgery It requires an open chest minor surgery

The battery can be replaced only by minor surgery.

The battery can be easily replaced any defect or
Further any defect or adjustment in the circuit cannot
adjustment in the circuit can be easily attended without
be easily attended. Doctors help is necessary to rectify
getting any help from a medical doctor
the defect in the circuit.

During placement swelling and pain do not arise During placement swelling and pain arise

There is no safety for the pacemaker particularly in the

There is a cent percent safety
case of children

Mostly there are used for temporary heart damages. Mostly there are used for permanent heart damages

Different modes of operation:

➢ Pacing modes can be either competitive or noncompetitive.
➢ Asynchronous pacing is called competitive because the fixed rate impulses may occur along with
natural pacing impulses and competition with them in controlling the heartbeat.
➢ Noncompetitive pacemakers are programmed either in demand or synchronized mode
➢ Based on the modes of operation pacemaker can be divided in to five types.
1) Ventricular Asynchronous pacemaker (Fixed rate pacemaker)
2) Ventricular synchronous pacemaker
3) Ventricular inhibited pacemaker (Demand pacemaker)
4) Atrial synchronous pacemaker
5) Atrial sequential Ventricular inhibited pacemaker

(i)Ventricular Asynchronous pacemaker (Fixed rate pacemaker):

➢ It can be used in atrium or ventricle. It has the simplest mechanism and the longest battery life. This
pacemaker is suitable for patients with either a stable, total AV block, a slow atrial rate.
➢ It is basically a simple astable multivibrator which produces at a fixed rate of heart.There may be
competition between the natural heart beats and pacemaker beats.
➢ If the pacemaker impulses reach the heart during a certain period, ventricular fibrillation may occur.
➢ Nowadays the fixed pacemaker is fabricated on a large-scale integrated circuit are used. The circuit
consists of a square wave generator and a positive edge triggered monostable multivibrator.
➢ The output of this combination provides a positively and negatively going square waves with equal
duration for positive and negative pulses.
➢ The period of square wave generator is given by T= -2RC ln(1-α/1+α)
Where α=R2/(R1+R2) α – feedback voltage fraction
➢ T can be changed by changing α or time constant RC. The square wave generator is nothing but
astable multivibrator which switches the output voltage between |Vsat |and -|Vsat|.

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➢ The output of square wave generator in coupled to the positive edge triggered monostable
multivibrator circuit. A positive edge trigger input will pass through capacitor C c and diode and will
raise the voltage at non-inverting terminal of second amplifier.

Fig: Ventricular Asynchronous pacemaker

➢ The capacitor Cc is chosen so as to make five times constant equal to pulse duration TD. Otherwise
the trigger would still be present after TD has passed and second pulse would be wrongly
generated.
➢ Normally the pulse duration should not be affected by the loading of heart tissue.
Disadvantages:
1) Using fixed rate pacemaker, the heart rate cannot be increased
2) Simulation with a fixed impulse frequency results in the ventricles and atria beatingat different
rates. This varies the stroke volume of heart and causes some loss in cardiac output.
3) Possibility of ventricular fibrillation will be more.

(ii)Ventricular synchronous pacemaker (standby pacemaker):

➢ This is used for patients with only short periods of AV block or bundle block. This type does not
complete with the normal heart activity.
➢ A single transverse electrode placed in the right ventricle both senses R wave and delivers the
stimulation. Thus, no separate sensing electrode is required.
➢ R wave triggers ventricular synchronized pacemaker which provide an impulse falling in lower part
of normal QRS complex.
➢ Atrial generated ventricular contractions generate R wave. Impulses are provided only when the
atrial generated ventricular contractions are absent.

Fig: Ventricular synchronous pacemaker

Working:
➢ Using the sensing electrode heart rate is detected and is given to the timing circuit in pacemaker.
➢ If the detected heart rate is below a minimum level the fixed rate pacemaker is turned on.
➢ If natural contraction occurs asynchronous pacer’s timing circuit is reset so that it next pulse will
detect heartbeat. Otherwise asynchronous pacemaker produces at its preset rate.
➢ The pacemaker may detect noise and interpret as its ventricular excitation. This can be eliminated
by refractory period or gate circuit.
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➢ In heart blocks P waves with respect to ventricular excitation. P and R waves have different frequency
bands.
➢ The high pass filter completely eliminates P-waves and the R-waves. Input amplifier increases peak-
to-peak amplitude of R-wave.
Advantages:
1) It can be used to arrest ventricular fibrillation
2) If the R-wave occurs with its normal value in amplitude and frequency then it would not work. Hence
the power consumption is reduced and no side effects.
3) When the R-wave is appearing with lesser amplitude, the circuit amplifies it and delivers in proper
form
4) If the R-wave amplitude is too low or too high the asynchronous pacer works to return the heart in
to normal one.
Disadvantages:
1) Atrial and ventricular contractions are not synchronized.
2) In olden type pacemaker the circuit is more sensitive to external electromagnetic interference.

(iii)Ventricular inhibited pacemaker (Demand pacemaker)

➢ It is also known as R-wave inhibited pacemaker. If the normal heart rate falls below minimum the
pacemaker will turn on and provide the heart a stimulus. Hence it is called as Demand pacemaker.
➢ There is a piezoelectric sensor shielded inside the pacemaker. When the pacemaker can
automatically increase or decrease its rate. Thus, it can match with greater physical effort.
➢ The sensing electrode pick up R-wave. The refractory circuit provides a period of time for the sensed
R-wave. The sensing circuit detects the R-wave resets the oscillator.
➢ The reversion circuit allows the amplifier to detect R wave in the low-level SNR. IN the absence of R
wave oscillator in timing circuit delivers pulses at its preset rate.
➢ The timing circuit determines the pulse rate of pulse generator. The output of timing circuit is fed in
to the pulse width circuit which is an RC network.
➢ The pulse width circuit determines the duration of pulse delivered to heart. Rate limiting circuit
limits the pacing rate to a maximum of 120pulses/min.
➢ Output circuit provides a proper pulse to stimulate the heart. The timing circuit, pulse width circuit,
Rate limiting circuit and output circuit are used to produce the desired pacemaker pulses to pace the
heart.

Fig: Ventricular inhibited pacemaker

➢ A special circuit called voltage monitor senses the cell depletion and signals in rate slow down
circuit energy compensation circuit.
➢ The rate slowdown circuit shuts off some of the current to timing network to slowdown
8±3beats/min during cell depletion.

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➢ The energy compensation circuit increases the pulse duration to maintain constant simulation
energy to heart.

(iv) Atrial synchronous pacemaker:

➢ It is used for young patient with a mostly stable block. Atrial pacing is a temporary pacing and has
many uses in physiologic investigation.
➢ It is used in stress testing and coronary artery diseases. It can act as a temporary pacemaker for
atrial fibrillation.
➢ The atrial activity is picked up by a sensing electrode placed in the dorsal wall of atrium.
➢ The detected p wave is amplified and a delay of 0.12sec is provided by AV delay circuit. The signal is
then used to trigger the resettable multivibrator.
➢ The output of multivibrator is given to amplifier which produce the desired stimulus to heart.
➢ The stimulus is delivered to the ventricle through the ventricular electrode. If the rate of atrial
excitation becomes too fast or too slow a preset fixed rate pacemaker is used.

Fig: Atrial synchronous pacemaker

(v)Atrial sequential Ventricular inhibited pacemaker:

➢ It has the capability of stimulating both atria and ventricles.
➢ If atrial function falls this pacemaker will stimulate the atrium and then sense the subsequent
ventricular beat.
➢ If atrial beat is not conducted to ventricle the pacemaker will fire the ventricle at a preset interval
of 0.12sec.

DEFIBRILLATOR:
➢ A Defibrillator is an electronic device that creates a sustained myocardial depolarization of a patient’s
heart in order to stop ventricular fibrillation or atrial fibrillation.
➢ Ventricular fibrillation is a serious cardiac emergency resulting from asynchronous contraction of
heart muscles. This results from electric shock or abnormalities of body chemistry.
➢ Hence it causes a steep fall of cardiac output and can lead to death if adequate steps are not taken
promptly.
➢ Ventricular fibrillation can be converted to a more efficient rhythm by applying a high voltage shock
to the heart. This voltage causes all muscle fibers to contract simultaneously. The instrument for
administering the electric shock is called defibrillator.
➢ The sudden cardiac arrest can be treated using a defibrillator and 80% of patient’s will be cured if
the treatment is given within one minute of attack.
➢ An atrial fibrillation causes reduced cardiac output but is usually not fatal. It happens for the young
people who are always smoking and can even be cured by drug therapy.
➢ Types of defibrillators: There are two types of defibrillators based on electrodes placement (i)Internal
defibrillator (ii) external defibrillator
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(i)Internal Defibrillator:
➢ It is used when the chest is opened. It uses large spoon shaped electrodes with insulated handle.
Since the electrodes are direct contact with heart the contact impedance is about 50Ω. The current
passes through the heart is of 1 to 20A.

Fig: Spoon Shaped ElectrodeFig: Paddle Shaped Electrode

(ii)External defibrillator:
➢ External defibrillator is used on the chest using paddle shaped electrodes. The bottom of the
electrode consists of a copper disc and is attached with highly insulated handle. The required
voltages are from 1000 to 6000V.
➢ When the electrodes are placed on the chest after the application of electrode gel the contact
impedance on the chest is about 100Ω.
➢ The D.C defibrillator is designed to deliver 50 to 400J of energy through thorax. The duration of
shock is about 1 to 5ms. The current flowing through the chest is about 10 to 60A.
➢ Depending upon the nature of voltage applied the defibrillators can be divided in to six groups.
1. A.C defibrillator
2. D.C defibrillator
3. Synchronized D.C defibrillator
4. Square pulse defibrillator
5. Double square pulse defibrillator
6. Biphasic D.C defibrillator

1. A.C defibrillator:
➢ It is the earliest and simplest type of defibrillator. It has appropriate voltages for both internal and
external defibrillation. It consists of a step-up transformer with various tappings on secondary side.

Fig: A.C defibrillator

➢ An electronic timer circuit is connected to the primary of the transformer. The timer connects the
output of the electrodes for a preset time.
➢ The timing device may be simple capacitor and resistor network which is triggered by a push button
switch. The duration of shock may vary from 0.1-1sec depending upon the voltage to be applied.
➢ For safety the secondary coil of transformer should be isolated from earth so that there is any shock
risk to anyone.
➢ For external defibrillation the voltages are in the range from 250 to 750V. For internal defibrillation
the voltage is from 60 to 250 V.
➢ External defibrillation requires large currents for the simultaneous contraction of heart muscle fiber.
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➢ This current also results in occasional burning of skin under the electrodes. Further it produces
atrium fibrillation while arresting ventricular fibrillation.

2. D.C defibrillator:
➢ D.C defibrillator would not produce undesirable side effects and at the same time it produces normal
heart beat effectively.
➢ Ventricular fibrillation is terminated by passing a high energy shock through discharging a capacitor
to exposed heart or chest of patient.
➢ A variable auto transformer T1 forms the primary of a high voltage transformer T2. The output
voltage of transformer T2 is rectified by a diode rectifier and is connected to a vacuum type-high
voltage change over switch.
➢ In position ‗A‗ the switch is connected to one end of an oil filled capacitor. In this position the
capacitor charges to a voltage set by the positioning of auto transformer.
➢ During the delivery of shock to patient a push button switch mounted on handle of electrodes
operated. The high voltage switch changes to position ‗B‗ and the capacitor is discharged across the
heart through electrodes.
➢ An inductor ‗L‗ is placed in one of the electrodes leads so that the discharge from the capacitor is
slowed down by the induced counter voltage.
➢ The shape of waveform that appears across the electrodes will depend upon the value of capacitor
and inductor and it’s the amplitude depends upon the discharge resistance.
➢ The success of defibrillation depends upon the energy stored in the capacitor and not with the voltage
used. For internal defibrillation 100J of energy is required whereas for external defibrillation 400J
are required. The discharging duration is from 5ms to 10ms.

Fig(a): D.C defibrillator (ordinary type) and its output

Dual peak d.c defibrillator:

➢ The passage of high current may damage the myocardium and the chest wall. To reduce this risk
some defibrillators, produce dual peak waveform this keeps the stimulus at peak for longer
duration.

Fig(b): Dual peak d.c defibrillator Fig(c): output of Dual peak d.c defibrillator

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➢ Some energy can be applied to the heart with low current level such defibrillators are called dual
peak defibrillators or delay line capacitance discharge d.c defibrillators.

Truncated defibrillator:
➢ In this type the capacitor discharge is adjusted so that the effective defibrillation is obtained at the
desirable low voltage level. The voltage level of the wave is almost constant but its duration is
extended to obtain the required energy.

Fig: Truncated defibrillator discharge waveform

3. Synchronized D.C defibrillator:

➢ Defibrillator is a risky procedure since if it is applied incorrectly it could induce fibrillation in a
normal heart. It is essential to use a defibrillator with synchronizer circuit.
➢ There are two zones in a normal cardiac cycle. T wave and U wave segments‗. If the counter shock
falls in the T wave segment then the ventricular fibrillation is developed.
➢ If the counter shock falls in the U wave segment then the atrial fibrillation is developed.

Fig : Modern d.c defibrillator circuit

➢ Fig. shows the modern d.c defibrillator circuit consisting of defibrillator electrocardioscope and
pacemaker.
➢ The pacemaker is used in case of emergency as a temporary pacing. It includes
a) Diagnostic circuitry used to assess the fibrillation before delivering the defibrillation pulse.
b) Synchronizer circuitry used to deliver the defibrillation pulse at the correct time so as to
eliminate the ventricular or atrial fibrillation without inducing them.

Working:
1. The electrocardiogram is obtained by means of an ECG unit connected to the patient who is going
to receive defibrillation pulse.
2. The switch is placed in the defibrillator mode if ventricular fibrillation is suspected.

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3. The QRS detector in that mode consists of a threshold circuit that would pass the signal as output if
R wave is almost in electrocardiogram. Otherwise it would not give any output if wave is present.
4. Meanwhile the medical attendant energizes the switch to deliver the defibrillation pulse.
5. AND gate ‗B‗ delivers signal to the defibrillator only when the R wave is absent, provided the signal
from medical attendant is also present at one of the two inputs of AND gate ‗B‗.
6. If any one of the inputs is missing then it would not give any output. By this way defibrillator is
inhibited and would not deliver the defibrillation pulse.
7. The fibrillation detector searches the ECG signal for frequency components above 150Hz. If they
are present fibrillation is probable and detector gives an output signal. A defibrillator pulse is
delivered only if the fibrillation detector produces an output at the same time that the attendant
energizes the switch. This is provided by the AND gate ‗C‗.
8. When AND gate ‗B ‗and ‗C‗ are simultaneously triggering the defibrillator the defibrillation pulse
is delivered.
9. In cardio version (or) synchronization mode the defibrillator is synchronized with ECG unit.
Suppose a patient is suffered by atrial fibrillation the doctor first diagnoses it correctly and then the
treatment is initiated using this circuit.
10. The ECG signal is given to QRS detector Its output is delayed with 30ms. At this time the ventricles
will be in uniform state of depolarization and the normal heart beat will not be disturbed. The delay
of 30ms after the occurrence of R wave allows the attendant to defibrillate atrium without inducing
ventricular fibrillation.

4. Square wave defibrillator:

➢ Here the capacitor is discharged through the subject by turning on a series silicon-controlled
rectifier (SCR).
➢ When sufficient energy has been delivered to the subject a shunt SCR short circuits the capacitor
and terminates the pulse.
➢ The output can be controlled by varying the voltage on capacitor or duration of discharge.
Defibrillation is obtained at less peak current and so there is no side effect.

Fig: Equivalent circuit of square pulse defibrillator and its output waveform

➢ In fig RD-Internal resistance of defibrillator, RE-electrode skin resistance,RT-Thorax resistance

➢ The energy in the pulse EP = VDIDTD
Where VD-Instantaneous voltage available from defibrillator pulse
ID-Instantaneous current available from defibrillator pulse,
TD-Duration of pulse
➢ Total circuit resistance R=RD+2RE+RT
Energy in the pulse can also be written in terms of voltage and resistance between the cable
attached to patient such that
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EP=ID 2 (2RE+RT)TD
• Energy loss in defibrillator EDL = ID2RDTD
• Energy loss in each electrode and skin EEL = ID2RDTD
• Energy delivered to thorax ET = ID2RDTD
➢ The energy delivered to the thorax can be expressed in the form of available energy from capacitor
discharge whose output is assumed to be a square pulse.
➢ Energy available from the capacitor EC = ET + 2 EEL + EDL
➢ Thus, ET is dismissed from available due to effects of RD and RE

5. Double Square Pulse Defibrillator:

➢ It is used normally after the open heart surgery. Conventional A.C and D.C defibrillators are
producing myocardial injury during the delivery of shock.
➢ If the chest is opened only lower energy electrics shock should be given. Instead of 800-1500V in
D.C defibrillators here 8-60V double pulse is applied with a mean energy of 2.4 watt-sec.
➢ When the first pulse is delivered some of fibrillating cells will be excitable and will be depolarized.

Fig: Double Square Pulse Defibrillator waveform

➢ Also cells which are refractory will continue to fibrillate. To obtain total defibrillation second pulse
operates on this latter group of cells.
➢ The pulse amplitude and width together with interval should be such that the cells defibrillated by
first pulse will be refractory to second pulse.
➢ The timing of second pulse should be such that those cells which were refractory to the first pulse
are now excitable. Hus complete defibrillation can be obtained by means of selecting proper pulse
space ratio.

Advantages:
• Using double square pulse defibrillator efficient and quick recovery of heart to beat in normal
manner without side effect like burning of myocardium or inducement of atrial or ventricular
fibrillation.
• The double square pulse with required pulse space ratio can be produced with the use of digital
circuits.

6. Biphasic D.C defibrillator:

➢ It is similar to double square pulse defibrillator such that it delivers D.C pulses alternatively in
opposite direction. This type of waveform is found to be more efficient for defibrillation of
ventricular muscles.

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DIALYZERS:
➢ Renal function: The natural kidneys in our body are used to eliminate the waste products formed
during bodily metabolism and regulate the concentration of the body fluid constituents. Even though
there are two kidneys in each body, a single kidney is capable of clearing all waste products in the
blood.
➢ The urine is formed by three processes, namely filtration of blood plasma, active secretion of urea,
uric acid and phosphates and reabsorption of water, glucose and sodium chloride.so that they are
restored to the blood. Each kidney contains about 1 to 1.25 million nephrons.
➢ Each nephron consists of a glomerulus which has done the filtration and several tubules which have
done the active secretion and reabsorption.
➢ Since the urine reflects the composition of the blood plasma, urinalysis is used in the diagnosis of
diseases that are accompanied by metabolic disorders. In the case of renal damage, the plasma
creatinine level in the urine is reduced below 7-14 millimole/day. Similarly, urea level in the urine is
also decreased in the case of renal failure.

Dialysis:
➢ Both acute and chronic renal failures can be treated successfully by dialysis which is a process by
which the waste products in blood are removed and restoration of normal pH value of the blood is
obtained by an artificial kidney machine.
➢ In dialysis, three physical processes called diffusion, osmosis and ultrafiltration are used to remove
the waste products. There are two types of procedures for doing dialysis, they are extracorporeal
and intracorporeal dialysis.
Extracorporeal Dialysis (Hemodialysis) Intracorporeal Dialysis (Peritoneal
dialysis)
Blood is purified by an artificial kidney machine
The peritoneal cavity in our body is used as a
called hemodialyzer, in which the blood is taken out
semipermeable membrane and by passing
from the body and waste products diffuse through a
the dialysate into it, waste products are
semipermeable membrane which is continuously
removed from the blood by diffusion
rinsed by a dialyzing solution or dialysate
More effective to separate the waste products Less effective
Technically complex and risk one because the blood
Simple and risk free
is taken out from the body
Dialysing time is about 3 to 6 hours Dialysing time is about 9 to 12 hours

Fig: Formation of urine from blood by nephrons

Hemodialysis:

➢ The below figure shows the principle of extracorporeal dialysis using hemodialyzer.

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Fig: Hemodialyser

Working:
1. 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 and
inserted below the skin in the hand by a minor operation, are used to take the blood from the artery
to the dialyzing unit. There should be a perfect protection against bacterial infection. By this way
the arterio-venous shunt can be used upto two years.
2. 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.
Blood flows in alternate spaces and the dialysate flows through the spaces is very small, then the
arterial pressure is enough to maintain the flow in the dialyzing unit where the blood pump is not
necessary.
3. The dialysate is an electrolyte. Through the cellophane sheets, urea, creatinine, uric acid and
phosphates are diffused from blood to dialysate.
4. There is a blood leak detector to detect rupture of a membrane. Further there are pressure
monitoring meters at the input and output. A thermostatic control is provided to maintain the blood
at 370C.
5. There are different forms of semipermeable membrane. It may be in the form of pressed planar
sheets or spiral tube in the form of a coil or a bundle of fibers.
Peritoneal Dialysis:

➢ The membrane in the peritoneal cavity in the abdomen is used as a semipermeable membrane. A
catheter is inserted in the abdomen through a puncture just below the navel. A sterile dialysate about
1.5 to 2 litres is allowed to flow into the peritoneal cavity
➢ The diffusion takes place in 10 to 30 minutes and the dialysate is then removed from the cavity. This
procedure is repeated 20 to 30 times to remove all the waste products from the blood.
➢ The above procedure is done in an automatic manner using electronic control circuitry. First the
dialysate is pumped into the abdominal cavity through the volume recording pump. The dialysate is
kept at 370C by thermostatic control, here thermistor is used as a sensing device.
➢ When a dialysate volume is about 2 litres, a timing circuit will first deliver a signal to stop the
dialysate flow into the abdomen. Next the timing circuit allows the diffusion time upto 30 minutes.

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Fig: Peritoneal dialysis

➢ After that it runs the sucking pump so that the dialysate in the abdominal cavity is pumped and sent
out through the drain. Once again, the volume of the outgoing dialysate is measured.
➢ When it reaches 2 litres, then the working of sucking pump is stopped and the fresh dialysate is
allowed once again to enter into the abdominal cavity through the volume recording pump.
➢ Thus, the above procedure is repeated 20 to 30 times. If the volume of the sucked dialysate is less
than 2 litres after diffusion is over, then an alarm circuit will work. Immediately the patient should
consult the doctor.

VENTILATORS:

➢ As a part of intensive care, the patients often require assistance with breathing. When artificial
ventilation is required for a long time, a ventilator is used to provide oxygen enriched, medicated air
to a patient at a controlled temperature.
➢ Ventilators can operate in different modes: controlled breathing where breathing is initiated by a
timing mechanism and Assisted breathing or patient-initiated breathing.
➢ Controlled breathing is an automatically timed breathing which is usually provided for patients who
cannot breathe on their own. It provides inspirations and expirations at fixed rates except during the
rest period for the patient.
➢ Assisted breathing the patients own spontaneous attempt to breathe in, causes the ventilator to cycle
on during inspiration. Thus, it is used for the patient who has difficult breathing due to high air way
resistance.
➢ There are servo-controlled ventilators which can switch automatically to any mode depending upon
the condition of the patient. This type of mode is called assist control mode. By this mode, the patient
controls his own breathing as long as he can, but if he should fail to do so, the control mode is able to
take over for him.
➢ The ventilator treatment gives the following
a) Adequate ventilation by which enough oxygen is supplied and the right amount of carbon
dioxide is eliminated.
b) Elimination of respiratory work
c) Increased intrathoracic pressure which prevents at electasis that is collapse of portions of
the lung and counteracts edema of lung.
1. Every ventilator operates cyclically. During inspiration air or some other gaseous mixture is pumped
into the lungs. During expiration the pressure ceases. This cycle is regulated by a mechanical,
pneumatic or electronic circuit. The regulation is obtained by pressure limited, volume limited and
servo-controlled systems.
a) Pressure limited ventilators are based on the principle that the inspiration is terminated
when the gaseous mixture pumped into the patients lungs reaches a pre set pressure. It is

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driven by the compressed gaseous mixture used for ventilation. These are so simple in
design and reliable in operation.
b) Volume limited ventilators are based on the principle that for each breath, a constant
volume of air is delivered. During inspiration the constant volume of air is sent into the
lungs by applying pressure to a chamber containing constant volume. It does not give the
desired ventilation in cases where the preset maximum pressure cannot completely empty
the chamber.
c) Servo-controlled ventilatorsare based on the usage of modern electronic control
techniques such that the flow to and from the patient is controlled by feedback circuits.
The electronic unit controls the amplifiers and logic circuits that control the ventilation. It
also monitors pressures, activates alarms and computed mechanical lung parameters.

Fig: Block diagram of a ventilator with its accessories

1. During patient’s inspiration, the air compressor draws room air through an air filter and passes it to
the main solenoid.
2. Main solenoid forces the bottom inlet valve of the internal bellows chamber to open and the lower
outlet valve to close.
3. Oxygen is passed into bellows chamber in a controlled manner by means of a control valve. The high
pressure in the bellows chamber compresses the bellows and forces the upper outlet valve to open.
Thus, the compressed oxygen enriched air is passed through the main solenoid into the external
tubes and then to the bacterial filter, humidifier, nebulizer, and finally to the patient’s lungs.
a) Humidifier: to prevent the patient’s lungs the applied air or oxygen must be humidified
either by heat vaporization or by bubbling an air stream through a jar of water.
b) Nebulizer: Compressor produces a fine spray of water or medication into the patients
inspired air in the form of aerosals. In a nebulizer the water or medication is picked up by a
high velocity jet of oxygen enriched air and thrown against one or more baffles into
controllable sized droplets which are then applied to the patient.
4. A sensitivity control monitors the negative pressure necessary to initiate inspiration when the
ventilator is used in the assisted mode. An aspirator or other types of suction apparatus is often
included as a part of the ventilator to remove mucus and other fluids from the airways.
5. When the medicated air is forced into lungs through the valve number 1, the spirometer is in closed
condition. When the inspiration is complete, the main solenoid switches the directions of the
pneumatic air to do the expiration cycle.

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Nebulizer is used to measure the volume of exhaled air so as to give an alarm to stop expiration and
to inspiration in the ventilator unit. During expiration, air is sucked into the spirometer chamber
through the valve number 1.
The volume of the chamber is varied by means of a light weight piston that moves freely in a cylinder
as air is withdrawn. A silastic rubber seal between the piston and the cylinder wall keeps the chamber
air tight.
The weight of the bellows causes the bottom bellows chamber outlet valve to open and the main
solenoid directs air to close the inlet valve of the internal bellows chamber. The spirometer alarm
indicates the correct volume of exhaled air from the lungs.
6. After the end of patient expiration, the system electronics trip the main solenoid, thereby initiating
the patient, inspiration part of the cycle.

MAGNETIC RESONANCE IMAGING SYSTEMS:

Principles of NMR Imaging Systems:
➢ The magnetic moments of the nuclei making up the tissue are randomly aligned and have zero net
magnetization (M = 0). When a material is placed in a magnetic field B0, some of the randomly
oriented nuclei experience an external magnetic torque which tends to align the individual parallel
or anti-parallel magnetic moments to the direction of an applied magnetic field.
➢ There is a slight excess of nuclei aligned parallel with the magnetic field and this gives the tissue a
net magnetic momentM0.
➢ With the magnetic moments being randomly oriented with respect to one another, the components
in the X-Y plane cancel one another out while the Z components along the direction of the applied
magnetic field add up to produce this magnetic moment M 0.
➢ According to the electromagnetic theory, the magnetic moment about the applied magnetic field with
a resonant angular frequency,w0 (called the Larmor frequency) are determined by a constant γ (the
magnetogyric ratio) and the strength of the applied magnetic fieldB 0. Each nuclide possesses a

characteristic value for γ butw0 and B0 are related as follows:

➢ The applied external magnetic field creates an energy absorption state from a statistical point of
view. When a nucleus with a magnetic moment is placed in a magnetic field, the energy of the nucleus
is split into lower (moment parallel with the field) and higher (anti-parallel) energy levels.
➢ The energy difference is such that a proton with specific frequency (energy) is necessary to excite a
nucleus from the lower to the higher state. The excitation energy E is given by the Planck’s equation

where h is Planck’s constant divided by 2p.

BASIC NMRI COMPONENTS:

➢ The basic components of an NMR imaging system are shown in Fig. These are:
• A magnet, which provides a strong uniform, steady, magnet field B0;
• An RF transmitter, which delivers radio-frequency magnetic field to the sample;
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• A gradient system, which produces time-varying magnetic fields of controlled spatial nonuniformity;
• A detection system, which yields the output signal; and
• An imager system, including the computer, which reconstructs and displays the images.
➢ There is a magnet which provides a strong uniform steady magnetic field B 0. Now a days
superconducting magnet are used in the MRI systems. The superconducting magnetic coils are cooled
to liquid helium temperature and can produce very high magnetic fields.
➢ Hence the SNR of the received signals and image quality are better than the conventional magnets used
in the MRI systems. Different gradients coil systems produce a time varying, controlled spatial
nonuniform magnetic fields in different directions.
➢ The patient is kept in this gradient field space. There are also transmitter and receiver RF coils
surrounding the site on which the image is to be constructed. There is a superposition of a linear
magnetic field gradient on to the uniform magnetic field applied to the patient.
➢ When this superposition takes place, the resonance frequencies of the processing nuclei will depend
primarily on the positions along the direction of the magnetic field gradient. This produces a one-
dimensional projection of the structure of the three-dimensional object.
➢ By taking a series of these projections at different gradient orientations using X, Y and Z gradient coils a
two- or three-dimensional image can be obtained. The slice of the image depends upon the gradient
magnetic field.
➢ The gradient magnetic field is controlled by computer and that field can be positioned in three-time
invariant planes (X, Y and Z). The transmitter provides the RF signal pulses. The received nuclear
magnetic resonance signal is picked up by the receiver coil and is fed into the receiver for signal
processing.
➢ By two-dimensional Fourier Transformation, the image is constructed by the computer and is displayed
on the television screen.

➢ Detection System: The function of the detection system (receiver) is to detect the nuclear
magnetization and generate an output signal for processing by the computer. A block diagram of a
typical receiver is shown in Fig. The receiver coil usually surrounds the sample and acts as an antenna
to pick up the fluctuating nuclear magnetization of the sample and converts it to a fluctuating output
voltage V(t).

Where M(t,x)is the total magnetization in a volume and B c(x)the sensitivity of the receiver coil at
different points in space.
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➢ Bc(x)describes the ratio of the magnetic field produced by the receiver coil to the current in the coil.
The receiver coil design and placement is such that B c(x) has the largest possible transverse
component.
➢ The RF signals constitute the variable measured in magnetic resonance tomography. These are
extremely weak signals having an amplitude in the nV (nano-Volt) range thus requiring specially
designed RF antennas.
➢ The sensitivity of an MR scanner depends on the quality of its RF receiving antenna. For a given
sample magnetization, static magnetic field strengths and sample volume, the signal-to-noise-ratio
(SNR) of the RF signal at the receiver depends in the following manner upon the RF-receiving
antenna.
SNR ~ K (Q/Vc)
Where K is a numerical constant, specific to the coil geometry Q is the coil magnetization factor, and
Vc is the coil volume.
➢ This implies that the SNR of an MR scan can be improved by maximizing the ratio of magnetization
to coil volume.
➢ The receiver coil is a matching network which couples it to the pre-amplifier in order to maximize
energy transfer into the amplifier. This network introduces a phase shift f to the phase of the
signal.The pre-amplifier is a low-noise amplifier which amplifies the signal and feeds it to a
quadrature phase detector.
➢ The detector accepts the RF NMR signal which consists of a distribution of frequencies centered
around or near the transmitted frequency w and shifts the signal down in frequency by w.
➢ The detector circuit accepts the inputs, the NMR signal V(t) and a reference signal, and multiplies
them, so that the output is the product of the two inputs. The frequency of the reference signal is the
same as that of the irradiating RF pulse.
➢ The output of the phase-sensitive detector consists of the sum of two components, one a narrow
range of frequencies centered at 2w0,and the other, a narrow range centered at zero.
➢ The low pass filter following the phase-sensitive detector removes all components except those
centered at zero from the signal. It is necessary to convert the complex (two-channel) signal to two
strings of digital numbers by analog-to-digital converters. The A-D converter output is passed, in
serial data form to the computer for processing.
The advantages of the NMR Imaging System are:

(i) The NMR image provides substantial contrast between soft tissues that are nearly identical in
existing techniques. NMR images that display T1 andT2properties of tissue provide tremendous
contrasts between various soft tissues, contrasts approaching 150% are possible in T1 and T2
images, while contrasts of only a few percent are possible between soft tissues with X-rays.
(ii) Cross-sectional images with any orientation are possible in NMR imaging systems.
(iii) The alternative contrast mechanisms of NMR provide promising possibilities of new diagnostics
for pathologies that are difficult or impossible with present techniques.
(iv) NMR imaging parameters are affected by chemical bonding and, therefore, offer potential for
physiological imaging.
(v) NMR uses no ionizing radiation and has minimal, if any, hazards for operators of the machines
and for patients.
(vi) Unlike CT, NMR imaging requires no moving parts, gantries or sophisticated crystal detectors.
The system scans by superimposing electrically controlled magnetic fields. Consequently, scans
in any pre-determined orientation are possible.
(vii) With the new techniques being developed, NMR permits imaging of entire three-dimensional
volumes simultaneously instead of slice by slice, employed in other imaging systems.

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ULTRASONIC IMAGING SYSTEMS:
➢ Ultrasound is a form of energy which consists of mechanical vibrations and the frequencies of which
are so high that they are above the range of human hearing.
➢ Most biomedical applications of ultrasound employ frequencies in the range of 1 to 15 MHz.
Velocities of ultrasound in soft tissues and bones are 1570 m/s and 3600 m/s respectively.
➢ Even though the therapeutic applications of ultrasonics are limited their diagnostic applications are
enormous. The doppler ultrasonic blood flowmeters are used to determine the flow rate of blood in
various blood vessels.
➢ Ultrasound can cure the malignant tumors (breast cancer) and it can be detecting the malignant and
ordinary benign tumors and also it can cure the acute pains in back and shoulders and can remove
the neurological disorders.
➢ Ultrasonography is a technique by which ultrasonic energy is used to detect the state of the internal
body organs. Bursts of ultrasonic energy are transmitted from a piezoelectric or magneto strictive
transducer through the skin and into the internal anatomy.
➢ When this energy strikes an interface between two tissues of different acoustical impedance,
reflections are returned to the transducer. The transducer converts these reflections to an electrical
signal. This electrical signal is amplified and displayed in an oscilloscope at a distance proportional
to the depth of the interface.
Construction of An Ultrasonic Transducer
➢ The construction of the transducer goes a long way in determining the resolution of the image. As we
know the vibrations of the piezo electric crystal produces the ultrasound waves. In the pulsed type
of ultrasound which is currently used for imaging, the vibrations have to be controlled effectively and
it is achieved by a process known as damping.
➢ Damping is done by a backing material which has to fulfill two conditions:
1. The impedance of the material and crystal must be the same. This will reduce the reflection
at the boundary, between the crystal and the material.
2. The sound waves going into the backing material must be totally absorbed. This helps in
transmission of short pulses of sound waves into the medium.
➢ A good damping material producing shorter pulse will improve the axial resolution. The second
consideration in the construction of the transducer is the matching layer, which is a material
mounted in front of the crystal. This helps not only in better transmission of the sound waves into
the medium but also to reduce the reflections at the transducer skin interface.
➢ The thickness of the matching layer should be usually ¼ of the wavelength. It is otherwise called as
quarter wave matching layer.
➢ The thickness of the crystal and its diameter also play an important role in the transducer. Thicker
the crystal, lower the frequency.
➢ Various types of transducers are available.
1. Static
2. Real time
i. Linear: No of elements arranged side by side and image produced has a rectangular
format.
ii. Sector: can be mechanical or electronically switched and are essential for imaging the
brain, for cardiac imaging, and for pelvic scans.
a) Mechanical
b) Annular array
c) Phased array

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iii. Convex array: No of elements like the linear array but these elements are arranged
in a curvilinear fashion. It produces a trapezoid shaped image format.
Advantage: Can have a very wide far field view, Higher the frequency better the
resolution poorer the penetration.
Display:

➢ The reflected echoes are now displayed on the screen as a useful image. The various modes of display
are A mode, B mode, M mode or T-M mode.
➢ A mode (Amplitude modulation): The reflected echoes are depicted as vertical spikes along the
horizontal baseline. This mode is primarily used in ophthalmology and echoencephalography.
➢ B mode (brightness modulation): the reflected echoes are depicted as dots on the screen. Every
reflection produces a single dot. The brightness of the dot depends on the intensity of the reflected
echo.
➢ T-M mode (Time motion mode): We have unidimensional graphic representation of two-dimensional
structures. It is primarily used to study moving objects like the values and the walls of the heart.
Usually the machine has a line called the M- Cursor. By positioning the cursor at the required point
we can get an M mode tracing of the heart at that point. M mode is very useful in studying cardiac
function, by making various accurate measurements of the chambers and valve movements.

Ultrasonic Imaging Instrumentation:

➢ The figure shows the block diagram of modern computer controlled ultrasonic image forming
system. It consists of so many peripheral sub units which are controlled by a computer through the
control buses.
➢ Transducer position data are fed to the computer. The computer sends this information to signal
processing unit which also receives the signal from the receiver.
➢ Then, it controls the receiver sensitivity also. Proper depth gain compensation is calculated by the
computer and given to the signal processing unit.
➢ The ultrasonic velocity is calculated and given to display unit. Here there is no drift, noise and
nonlinearity which are normally associated with analog devices.
➢ By using the image storage unit, the patient information data can be displayed again leisurely for
detailed examination.

Fig: Block diagram of a computer controlled ultrasonic image forming system.

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➢ The current state of ultrasonic imaging technology though makes use of microcomputers for control
functions, it is difficult to carry out direct real time image processing. The ultra-high-speed analog to
digital converters have enabled straight digitization of the high frequency signals. Thus, the digital
real time scanners are used for displaying ultrasound images.
➢ The echoes from the patient body surface are controlled by the receiver circuit. Proper depth gain
compensation is given by DCG circuit.

Fig: Digital real time ultrasonic scanner

➢ The received signals are converted into digital signals and are stored in the memory. Meanwhile the
scan converter control receives signals of transducer position and TV synchronous pulses and
generates X and Y address information which is fed to the digital memory.
➢ The stored digital image signals are processed and colour coded and are given to digital to analog
converter.
➢ Finally, they are fed into video section of the television monitor. By this circuit operations can be
performed quickly with higher frequency.

PART A
1. Give two important factors that demand internal pace maker’s usage. (Nov/Dec-2013)
The two important factors that demand internal pace maker’s usage are
(i). Type and nature of the electrode used
(ii). Nature of the cardiac problems.
(iii). Mode of operation of the pacemaker system.

2. Classify Pacing modes

Based on the modes of operation of the pacemakers, they can be classified into five types. They are:
1. Ventricular asynchronous pacemaker(fixed rate pacemaker)
2. Ventricular synchronous pacemaker.
3. Ventricular defibrillator inhibited pacemaker (demand pacemaker)
4. Atrial synchronous pacemaker.
5. Atrial sequential ventricular inhibited pacemaker.

3. What is meant by Nitrogen washout? (May/June-2014)

Nitrogen washout (or Fowler's method) is a test for measuring anatomic dead space in the lung during a
respiratory cycle, as well as some parameters related to the closure of airways.

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4. What types of electrodes are used in a defibrillator?
The electrodes used in a defibrillator are (i)Internal electrodes - Spoon shaped (ii)External electrodes –
Paddle shaped

5. What is meant by fibrillation?

The condition at which this necessary synchronism is lost is known as fibrillation. During fibrillation the
normal rhythmic contractions of either atria or the ventricles are replaced by rapid irregular twitching
of the muscular wall

6. Calculate the energy stored in 16μF capacitor of a DC defibrillator that is charged to a potential of 5000
Vdc.
Given Data: C = 16μF V= 5000 E= (1/2) CV 2 =(1/2) (16* 10-6) (25* 106)=200 Joules

7. What is meant by Dialyser?

Hemodialysis is a method for removing waste products such as creatinine and urea, as well as free
water from the blood when the kidneys are in kidney failure. The mechanical device used to clean the
patient's blood is called a dialyser, also known as an artificial kidney.

8. Distinguish between endocardiac and myocardiac electrode (Nov/Dec-2016)

Endocardiac electrode Myocardiac electrode
Endocardiac electrode are used in External Myocardiac electrode are used in Internal
pacemaker. pacemaker
Endocardiac electrode and are applied to heart Myocardiac electrode and are in contact with
heart muscle.

9. Mention two difference between internal and external defibrillator (Nov/Dec-2016)

Internal Defibrillator External defibrillator
Internal Defibrillator is used when the chest is External defibrillator is used on the chest
opened.
It uses large spoon shaped electrodes with It uses paddle shaped electrodes
insulated handle
Contact impedance of electrode is about 50Ω. Contact impedance of electrode gel is about
100Ω
The current passes through the heart is of 1 to The current flowing through the chest is about
20A. 10 to 60A

10. Why asynchronous pacemakers (Fixed rate pacemakers) no longer used? (Nov/Dec-2016)
1. Using fixed rate pacemaker the heart rate cannot be increased
2. Simulation with a fixed impulse frequency results in the ventricles and atria beating at different rates.
This varies the stroke volume of heart and causes some loss in cardiac output.
3. Possibility of ventricular fibrillation will be more.
4. There may be competition between the natural heart beats and pacemaker beats.

11. What is meant by Bradycardia and Tachycardia? (May/June 2015)

The normal value of heart rate lies in the range of 60 to 100 beats per minute. A slower rate than this is
called as Bradycardia (Slow rate) and a higher rate, Tachycardia (fast heart).

12. When does the need for pacemaker arise? What is its function? (Nov/Dec 2015)
In cardiac diseases, where the ventricular rate is too low, it can be increased to normal rate by using
pacemakers. The various arrhythmias (rhythm disturbance) that result in heart block and Adams stokes
attacks represent a serious pathological condition. During that time, the patient becomes invalid because
of the constant risk of sudden losing consciousness. By fixing the artificial electronic pacemakers, the
above defects in the heart can be eliminated.
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13. List the typical ranges of pacemaker parameters. (Nov/Dec 2014)

Pulse rate - 25-155pulses per minute
Pulse width - 0.1-2.3 ms
Pulse amplitude - 2.5-10 volts
Battery capacity - 0.44-3.2amp-hours
Longevity - 3.5-18 years
End-of-life indicator - 2-10%drop in pulse rate
Weight - 33-98 grams
Size - 22-80cm3
Encapsulization - Silicon rubber, Stainless steel, titanium

14. What is meant by demand pacemaker? (Nov/Dec 2013)

If the R wave is missing for a preset period of time, the pace will supply a stimulus. Therefore, if the
heart rate falls below a pre- determined minimum the pacemaker will turn on and provide the heart a
stimulus. For this reason, it is called as Demand Pacemaker.

15. What are the batteries used for implantable pacemakers? (Nov/Dec 2012)
The batteries used for implantable pacemakers are 1. Mercury cells 2. Lithium cells 3. Rechargeable cells
4. Nuclear cells 5. Bio Fuel cells 6. Bio Mechanical power generation sources.

16. Why should a patient susceptible to ‘ventricular fibrillation’ be watched continuously?

Ventricular fibrillation is far more dangerous, for under this condition the ventricles are unable to pump
blood and if the fibrillation is not corrected death will usually occurs within a few minutes. So, patient
should be watched continuously.

17. Why are asynchronous pacemaker no longer used? (june 2016)

Heart beat rate cannot be changed. If it is fixed in atrium, atrium beat at a fixed rate. If ventricle beat at
a different rate, and then it leads to a severe problem. Ventricular fibrillation may be occurred.

18. What is dialysate mentation its composition (june 2017)

Themakeup of dialysate or the dialysis 'bath', is: sodium chloride, sodium bicarbonate or sodium
acetate, calcium chloride, potassium chloride, and magnesium chloride. This is the general composition
of dialysate, but other compounds such as glucose may also be included.

19. What is the systolic and diastolic pressure of different areas of heart?
Left Ventricle: 130/5
Right Ventricle: 25/0
Left Atrium: 9/5
Right Atrium: 3/0

20. What is Systole and Diastole?

Systole is the period of contraction of the ventricular muscles during that time blood is pumped in to the
pulmonary artery and the aorta. Diastole is the period of dilation of the heart chambers as they fill with
blood.

21. What are the three physical processes used in dialysis?

The three physical process used in dialysis are i) Diffusion ii) Osmosis iii) Ultra filtration.

22. What are the two types of procedures for doing dialysis?
The two types of procedures for doing dialysis
1. Hemodialysis 2. Peritoneal dialysis

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23. Which type of electrode is applied in the case of external stimulation and what is the current range?
The paddle shaped electrodes are applied on the surface of the chest and the current range is 20 -150
mA.

24. Which types of electrodes are used in internal stimulation and what is the current range?
The electrodes in the form of fine wires of Teflon coated stainless steel, spoon like electrodes are
used.The current range in 2 -15 mA

25. What is external stimulation employed?

The external stimulation is employed to restart the normal rhythm of the heart in case of cardiac stand
still.

26. What is internal stimulation employed?

Internal stimulation is employed in cases requiring long term pacing because of permanent damage that
prevents normal self-triggering of heart.

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