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pilepsy Research (2011) 93, 84—86

journa l homepage: www.e lsev ier .com/ locate /ep i lepsyres

HORT COMMUNICATION

isk of choking and aspiration during inpatientideo-EEG monitoring

atherine H. Noe ∗, Lisa M. Tapsell, Joseph F. Drazkowski

ivision of Epilepsy, Department of Neurology, Mayo Clinic Arizona, Phoenix, AZ, USA

eceived 5 March 2010; received in revised form 26 October 2010; accepted 31 October 2010vailable online 30 November 2010

KEYWORDSAspirationpneumonia;Epilepsy;Seizure;Hypoxia

Summary Seizures can cause airway compromise and aspiration. This is a potential concernduring inpatient video-EEG monitoring (vEEG), where seizures are provoked for diagnostic pur-poses. The frequency of aspiration and efficacy of nursing interventions to protect the airwaywere evaluated in this retrospective study of 590 partial complex (PC) and generalized tonicclonic (GTC) seizures recording during vEEG. 33 seizures (5.6%) occurred while patients wereeating or drinking, 14 with food in the mouth at onset. 4 (0.6%) were followed by post-ictalemesis. Supplemental oxygen was provided in 93% of GTC seizures, and oral suctioning in 85%.

Lateral decubitus positioning was used in 53%. These interventions were applied in a minorityof PC seizures. There were no choking events, one suspected aspiration without subsequentcomplication, and no aspiration pneumonia. It is uncertain if interventions such as oral suction-ing, lateral decubitus positioning, or oxygen administration reduce the risk of aspiration duringvEEG.

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© 2010 Elsevier B.V. All righ

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spiration of food, oral secretions, or emesis can complicateeizures, and is the rationale for post-ictal lateral decubitusositioning (LDP). The frequency of aspiration in epilepsy is

oorly defined. Mortality from aspiration has been reportedn long-term care facility residents with refractory epilepsynd mental retardation (Klenerman et al., 1993, Day et al.,005). Frequent seizures and baseline airway impairment

∗ Corresponding author at: Mayo Clinic Hospital, 5E Departmentf Neurology, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.el.: +1 480 342 2581; fax: +1 480 342 2544.

E-mail address: noe.katherine@mayo.edu (K.H. Noe).

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920-1211/$ — see front matter © 2010 Elsevier B.V. All rights reserved.oi:10.1016/j.eplepsyres.2010.10.014

served.

ave been proposed contributors to high aspiration risk inhis group. However, in a 1 year retrospective study of5 institutionalized subjects with epilepsy and 977 adultsrom an outpatient epilepsy clinic, 0.2% of generalized toniclonic (GTC) seizures lead to aspiration pneumonia in bothopulations (DeToledo et al., 2004). Airway compromiseuring seizures is a safety issue during vEEG, where provo-ation of frequent seizures could lead to complications. Onerior study based on discharge diagnosis reported 2 cases ofspiration in 806 subjects with GTC seizures during vEEG.

DeToledo et al., 2004). No prior studies have detailed theircumstances in which aspiration occurred or included par-ial complex (PC) seizures. Our purpose was to quantify therequency, causes, and prevention of airway compromiseuring GTC and PC seizures during vEEG.

onitoring 85

Figure 1 Observed use of supplemental oxygen, oralsuctioning, and lateral decubitus positioning in partial com-plex and generalized tonic—clonic seizures. AbbreviationsPC = partial complex seizure GTC = generalized tonic—clonicsD

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Risk of choking and aspiration during inpatient video-EEG m

Methods

Following local institutional review board approval, Mayo Clinic Ari-zona vEEG admissions from January 1, 2006 to December 31, 2008were reviewed for adults with recorded PC or GTC seizures. Sim-ple partial, myoclonic, absence, atonic, and psychogenic seizureswere excluded as were intracranial montoring cases. 132 subjectsmet inclusion criteria. Mean age was 42 years (range 18—86 years).Each subject’s electronic medical record, radiology reports, EEGtechnologist and nursing notes, and ictal video and EEG for everyseizure were analyzed for: seizure type, timing and duration; EEGlocalization; correlation of seizure to eating or emesis, aspiration orchoking; ictal finger pulse oximetry; and use of oral suctioning, sup-plemental oxygen, or LDP. Statistical comparisons were performedusing chi-square tests for categorical variables and ANOVA for con-tinuous variables.

The Mayo Clinic Arizona EMU is a 6 bed unit integrated withina general neurology floor. Patients can drink and snack ad lib, butchewing gum and tobacco are disallowed. The unit is continuouslystaffed by registered nurses and vEEG technicians with specializedepilepsy training. Nursing staff provides bedside assessment andcare (including supplemental oxygen, suctioning, and LDP) per stan-dardized protocols and real time assessment of need. Post-ictal vitalsigns including finger pulse oximetry are part of the recommendedprotocol, however continuous pulse oximetry during vEEG was notroutinely utilized.

Results

590 seizures were analyzed: 465 PC, 100 secondary GTC,and 25 primary GTC. A median of 3 seizures per subject(range 1—48) was recorded. Seizure origin was temporal in

58% (n = 341), extratemporal in 37% (n = 221), and general-ized in 5% (n = 28). Supplemental oxygen was provided in230 (39%) seizures, oral suctioning in 131 (22%), and LDP in72(12%). Supplemental oxygen, oral suctioning, and reposition-ing were used in most GTC, but less than ¼ of PC seizures

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Table 1 Outcome of recorded seizures with foodstuff in the mou

Aspiration risk Seizuretype

Seizurelocalization

Seizureduratio

1 Food in mouth PC Temporal 28 s2 Food in mouth PC Temporal 120 s3 Food in mouth PC Temporal 60 s4 Food in mouth PC Temporal 110 s5 Food in mouth PC Temporal 60 s6 Food in mouth PC Temporal 300 s7 Food in mouth PC Frontal 30 s8 Food in mouth PC Frontal 12 s9 Food in mouth PC Frontal 55 s10 Food in mouth GTC Temporal 120 s11 Food in mouth GTC Temporal 65 s12 Food in mouth GTC Frontal 221 s13 Food in mouth GTC Generalized 120 s14 Food in mouth GTC Generalized 65 s15 Emesis PC Temporal 120 s16 Emesis PC Frontal 30 s17 Emesis PC Frontal 40 s18 Emesis GTC Frontal 108 s

Abbreviations: O2 sat. = post-ictal oxygen saturation, CXR = chest X-raseizure; s = seconds, O2 = supplemental oxygen, S = oral suctioning, LD =

eizure, O2 = supplemental oxygen, Suction = oral suctioning, Latecub = lateral decubitus positioning.

Fig. 1). These differences in utilization by seizure type weretatistically significant (p < 0.001, chi square).

There were no cases of choking or aspiration pneumonian the 590 seizures analyzed. 33 seizures (5.6%) occurredhile subjects were eating or drinking. In 14 food wasbserved in the mouth at seizure onset (Table 1). Clinicaluspicion for possible aspiration was noted in one case, withubsequent evaluation showing no clinical or radiologic evi-ence of pneumonia. The subject in question had normal

ognition and swallowing. Post-ictal emesis was noted inseizures, and was not associated with hypoxia or aspira-

ion (Table 1). The lack of demonstrable airway compromiser aspiration in the 18 subjects who had food or vomitus

th or with post-ictal emesis.

nNursinginterventions

O2 sat. Suspectedaspiration

CXR

None — No —O2 94% No —O2 89% No —None 95% No —O2 94% No —None 97% No —None — No —None — No —None — No —None — No —O2, S, LD 99% No —O2, S, LD 94% Yes wnlO2, S, LD 100% No —O2, S, LD 98% No -S 91% No —None — No —None — No —O2, S, LD 95% No —

y, PC = partial complex seizure, GTC = generalized tonic—cloniclateral decubitus position.

86 K.H. Noe et al.

Table 2 Interventions to maintain airway and oxygenation in seizures experienced by subjects with post-ictal emesis or foodin the mouth (‘‘high risk’’ population) as compared to general use.

Oxygen Oral suction Lateral decubitus

Partial complex seizures Total (n = 465) 114 (24.5%) 25 (5%) 6 (1%)‘‘High Risk’’ (n = 12) 3 (25%) 1 (8%) 0

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Generalized tonic—clonic seizures Total (n = 125)‘‘High Risk’’ (n = 6)

n the mouth in the peri-ictal period was not explained byifferences in nursing intervention (Table 2).

iscussion

his series of PC and GTC seizures during vEEG suggests thathoking and aspiration are rare, even in seizures with eatingr emesis. Clinical concern for aspiration was present in only/125 (0.8%) GTC and 0/465 PC seizures. This is consistentith prior report of aspiration pneumonia in 0.2% of sub-

ects with GTC seizures in an EMU setting (DeToledo et al.,004).

Significant morbidity and mortality are unacceptable foroluntary diagnostic tests like vEEG. While the frequencyf complications during voluntary vEEG is low (Noe andrazkowski, 2009), precautions against rare adverse eventsre appropriate when they are low cost, low risk, effec-ive and easy to perform. Based on this case series, it is

ncertain if oral suctioning, LDP, or oxygen administrationeduce the risk of aspiration in persons with epilepsy under-oing vEEG. LDP is often recommended as epilepsy first aid.lthough one study suggesting positioning during a GTC mayause shoulder dislocation (DeToledo and Lowe, 2001), there

N

116 (93%) 106 (85%) 66 (53%)5 (83%) 5 (83%) 5 (83%)

s little evidence to contraindicate use of this technique. These of supplemental oxygen and oral suctioning by trainedroviders, based on clinical judgment of need, appears toe low risk in the vEEG setting. If there is a downside tohese measures, it may be in setting a standard of seizurentervention for patients and family that is both unnecessarynd difficult to recreate outside the vEEG setting.

eferences

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eToledo, J.C., Lowe, M.R., Gonzalez, J., Haddad, H., 2004. Risk ofaspiration pneumonia after an epileptic seizure: a retrospectiveanalysis of 1634 adult patients. Epilepsy Behav. 5, 593—595.

eToledo, J.C., Lowe, M.R., 2001. Seizures, lateral decubitus, aspi-ration, and shoulder dislocation. Neurology 56, 290—291.

lenerman, P., Sander, J.W., Shorvon, S.D., 1993. Mortality in

patients with epilepsy: a study of patients in long term resi-dential care. J. Neurol. Neurosurg. Psychiatry 56, 149—152.

oe, K.H., Drazkowski, J.F., 2009. Safety of long-term video-electroencephalographic monitoring for evaluation of epilepsy.Mayo Clin. Proc. 84 (6), 495—500.