Why Patients Are Placed in the Lateral (Recovery) Position During Seizures
Patients should be placed on their side in the recovery position during seizures primarily to reduce the risk of aspiration if vomiting occurs during the seizure or in the postictal period, and to facilitate drainage of airway secretions. 1
Primary Rationale for Lateral Positioning
The recovery position serves a critical protective function:
- Aspiration prevention: The lateral position is specifically intended to reduce the risk of aspiration if the person vomits during the seizure or the postictal period. 1
- Airway secretion drainage: This position facilitates drainage of airway secretions and reduces the risk of airway obstruction in individuals with decreased responsiveness. 1
- Airway patency maintenance: When the airway cannot be closely monitored by a first aid provider, the recovery position helps maintain airway protection. 1
Important Timing Consideration
There is emerging evidence suggesting that lateral positioning should ideally be performed AFTER the convulsive movements stop, not during active convulsions. 2, 3
Evidence for Post-Seizure Positioning:
- Aspiration timing: Aspiration is more likely in the postictal phase rather than the ictal (active seizure) phase of a generalized tonic-clonic seizure, when oral secretions are not usually increased and there is cessation of respiratory movements. 3
- Low aspiration risk during seizure: In one study of 733 adults with intractable seizures, only 2 developed aspiration pneumonia after a generalized tonic-clonic seizure over a 2-month period, suggesting aspiration during the active seizure phase is uncommon. 3
Potential Risks of Positioning During Active Seizure:
- Shoulder dislocation: Positioning patients in lateral decubitus while still convulsing can result in shoulder dislocations (risk <1%), with the dislocated shoulder occurring on the lower side. 3
- These dislocations can result in disabling recurrences and require surgery, but are easily preventable by waiting until convulsions cease. 3
- Delayed cardiac arrest recognition: Lateral positioning during ongoing convulsions may hinder recognition of cardiac arrest. 2
Current Guideline Recommendations
Despite the nuanced evidence, current American Heart Association and American Red Cross guidelines (2024) recommend placing the person on their side in the recovery position as part of minimizing injury risk during seizures. 1
The guidelines specify that first aid providers should:
- Help the person to the ground
- Place the person on their side in the recovery position
- Clear the area around them
- Stay with the person having a seizure 1
Clinical Caveats
Continuous monitoring must continue even after positioning, as the recovery position does not eliminate the need to watch for signs of airway occlusion, inadequate or agonal breathing, and unresponsiveness. 4
When Recovery Position Is Most Critical:
- Decreased level of responsiveness: Particularly important when the person has reduced alertness. 4, 1
- Risk of airway obstruction: Essential when the person is at risk for airway obstruction (decreased alertness, active vomiting) or cannot be continuously watched. 1
- Postictal period: Most beneficial for an unresponsive, normally breathing person after seizure activity stops, as it can prevent life-threatening respiratory disturbances. 2
Practical Algorithm
- During active convulsions: Protect from injury by clearing the area and cushioning the head, but consider waiting to turn the patient until convulsions cease to avoid shoulder dislocation 3
- After convulsions stop: Immediately place in lateral recovery position if the person remains unresponsive 2, 3
- Monitor continuously: Watch for airway obstruction, inadequate breathing, or return of seizure activity 4
- Activate EMS: If seizure lasts >5 minutes, multiple seizures occur, or person doesn't return to baseline within 5-10 minutes 1
Note: There is no specific evidence supporting "left" lateral position over "right" lateral position—either side is acceptable for the recovery position. The key is achieving a stable lateral position that maintains airway patency and allows drainage of secretions.