Seizures, lateral decubitus, aspiration, and shoulder dislocation: Time to change the guidelines?

The recommendation to position a patient having a seizure on a lateral decubitus is aimed at minimizing the risk of aspiration. The authors reviewed the database of the Epilepsy Foundation Clinic of South Florida for patients with epilepsy treated for pneumonia between May 1999 and May 2000 and patients admitted to two university telemetry units who had dislocation of the shoulder during an epileptic seizure. Over 2 months, 2 of 733 adults with intractable seizures had aspiration pneumonia after a generalized tonic clonic seizure (GTCS). Although no study has specifically addressed the problem of aspiration pneumonia in adults with GTCS, our findings suggest this problem is not common. From the two epilepsy centers, 5 of 806 patients dislocated a shoulder during a seizure. Video recordings showed that these patients were positioned in a lateral decubitus by staff while still having the convulsion. The dislocated shoulder in all cases was on the lower side. The risk of shoulder dislocation in a convulsing patient positioned in a lateral decubitus is less than 1%. Nevertheless, dislocations can result in disabling recurrences and are easily preventable. Because aspiration is more likely in the postictal rather than ictal phase of a GTCS, when oral secretions are not usually increased and there is cessation of respiratory movements, lateral decubitus should only be implemented after cessation of the convulsion. In inpatients (such as those on telemetry), secretions may be better managed by bedside aspiration of the oral cavity.