Introduction

Despite recent advances in pharmacology and the completion of a major controlled therapeutic trial (40), status epilepticus (SE) remains a major medical emergency and a persistent, serious public health problem in the United States. Population-based studies indicate that it is still associated with a 27% mortality in adults, and with very serious morbidity in survivors (8). In terms of the amount of clinical research devoted to it and the education of the medical public, SE is very much an orphan disease and probably should be defined as such. Those who frequently see and treat SE rarely study it. Most SE is treated in emergency departments (EDs) and in intensive care units (ICUs), but essentially all the research work on the topic is published in the neurology literature. By the same token, most of those who study SE in the experimental laboratory (and this is a small number of laboratories) rarely treat it. The extent to which this lack of education of the medical public might account for the poor outcome of treating SE is unknown. At the Santa Monica meeting, we surveyed the audience as a first step in the study of that problem. The survey addressed therapeutic attitudes and therapeutic protocols, and it targeted a medical public that is clearly not representative of the medical profession as a whole. However, the meeting participants were likely to know more about SE than the average emergency physician or neurologist, so that any lack of education that might be detected would be likely to underestimate the extent of the problem and its impact on the poor outcome of SE. The results of that survey are discussed in this chapter. We have also added to that discussion some therapeutic algorithms that are currently in use at our center (the West Los Angeles Veterans Affairs Medical Center) in order to highlight some of the issues raised by the survey regarding the current treatment of SE. Recent estimates of the outcome of SE suggest that it is still responsible for approximately 30,000 deaths yearly in the United States (8, 13, 36; see also Chapters 2 and 3), and comparisons with the figures available at the time of the first Santa Monica Symposium on Status Epilepticus in 1980 (7) suggest that this number may represent an improvement of only about 20,000 deaths per year over the outcome estimated at that time. The Veterans Affairs Status Epilepticus Cooperative Study has provided type I evidence of the profound loss of efficacy of pharmacologic treatment once the first two drugs fail. Our therapeutic strategies try to address one of the possible causes of this failure, by using short-acting medications for a limited period of time, so that, if the first drug or drugs fail, the lingering cardiovascular depression due to those agents does not prevent delivery of a full dose of the next agent.