Pain control and medicines

Through its Department of Essential Drugs and Medicines Policy (EDM), the WHO has developed a model list of medicines which have been selected to address major public health problems, for which there is documented evidence of efficacy and safety, and which are cost-effective (46). This model list contains 325 medicines that the WHO recommends should be available within a functioning health system at all times in adequate amounts, in appropriate dosage forms, with assured quality and at an affordable price. As with the current guidelines, the Model list of essential medicines is intended to be adapted on a national basis. Currently, 156 countries have national essential medicines lists.

Almost all of the medications that would be needed for essential trauma care are already included in the WHO Model list of essential medicines. However, the availability of such essential medicines is still far from complete, especially in rural areas of low-income countries (47). Hence, the Guidelines for essential trauma care lay out some of the most critical drugs needed for the care of the injured. The EsTC list is drawn from the Model list of essential medicines. It is intended to promote greater availability of the trauma-related essential medicines. It also adds further definition as to levels of the health care system at which the various medicines should be considered essential, with respect to the care of injured patients.

In the accompanying table, medicines are grouped by the categories in the Model list of essential medicines. Not all of the 27 categories of the Model List are applicable. Only those which are applicable are listed in the Guidelines for essential trauma care. Within each category, the guidelines address only those medicines which are trauma-related.

In some cases, the Model list of essential medicines indicates a therapeutic group, in which various drugs could serve as alternatives. When this has been done, the Guidelines for essential trauma care indicate the drug followed by the term "or equivalent." In the Model List, drugs may be included in several categories. For example, diazepam is listed under both anaesthetics and anticonvulsants. For brevity, in Table 5.12, each medicine is listed only once.

By way of further explanation on Table 5.12, the Model list of essential medicines is divided into a core list and a complementary list. The core list contains medi cines that are efficacious, safe and cost-effective for major health problems. The complementary list contains medicines that are also efficacious and safe, but not necessarily as affordable as those on the core list. In the Guidelines for essential trauma care, almost any drug on the complementary list is listed as desirable rather than essential.

Likewise, many of the medicines listed might indeed be useful at the basic health care level. However, the great variations in what this level constitutes around the world prevent most of these medicines from being designated as essential. For example, in many locations, basic health care facilities do not provide injections or antibiotics. Hence, these guidelines do not list any of the antibiotics or any medication requiring injection as essential at this level. Depending on the capabilities of such basic health care facilities, some countries may wish to designate some of the medicines as essential at these facilities in their national plans.

The EsTC's list of medicines is not intended to be an exhaustive list of the medicines that might conceivably be needed by trauma patients. For example, in malaria endemic areas, postoperative fever is often due to recurrence of malaria. Antimalarial agents are covered extensively by the Model list of essential medicines, but not by the Guidelines for essential trauma care.

The Model list of essential medicines explains that the selection of these medicines is only one step, which needs to be followed by the appropriate use of these medicines. This implies that individuals who need them "receive the right medicine, in an adequate dose for an adequate duration, with appropriate information, planning of treatment follow up, and at an affordable cost" (46).This depends on factors such as regulatory decisions, procurement, training and information. As part of its Essential Drugs and Medicines programme, the WHO provides consultation to countries on these various factors as a means of increasing their capacity to provide essential medicines. Similar items might need to be addressed as part of the development of essential trauma care development. In particular, it is to be emphasized that, whatever pharmaceutical agent is being considered, the health care providers utilizing this agent should have sufficient training and skill to administer or prescribe it effectively and safely.

With respect to regulations and procurement, many of the medications in section 2 (Pain, fever and inflammation) of the Model list are subject to international control under the United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances (1988) and related conventions. In some cases, otherwise reasonably stringent international controls prevent the most effective analgesics from reaching those who need them, especially in rural, low-income areas (48). Trauma patients represent one of the largest groups of people in severe pain, and hence one of the largest groups in need of effective, affordable analgesics. Hence, suitably amending existing regulations or otherwise finding ways to assure the availability of inexpensive, effective, narcotic-level pain-relieving medications would be a key element in a plan for essential trauma care plan.

Most of the medicines in the accompanying table are self-explanatory or have been addressed in further detail in the Model list of essential medicines. A few points need to be mentioned. Medications from sections 3 (Anaphylaxis) and 4 (Poisonings) of the Model list are included here because of the possible need to treat complications of medicines elsewhere on the list, including allergic reactions to antibiotics and respiratory depression from narcotics. Under section 6 (Infections), only those antibiotics which generally pertain to care of the injured are included. Anti-tuberculosis medications and antimalarial agents (see above) are not included here, although they are in the Model list of essential medicines.

Blood products and plasma expanders (section 11 of the Model list), Cardiovascular disorders (section 12), and Fluid and electrolyte balance (section 26) are further explained in section 5.3 of these guidelines, on the topic of Circulation. The isotonic crystalloid solutions constitute the mainstay of resuscitation of hypotensive trauma patients, and their availability and appropriate use should be assured in every hospital where severely injured patients are treated. Although dopamine is considered to be an essential medicine in the Model list, the Guidelines for essential trauma care list it as desirable, because of the cost involved in adequately training both medical and nursing staff in the safe administration of pressors by continuous IV infusion.

Gastrointestinal medicines (section 17 of the Model list) are included primarily because of the need for peptic ulcer prophylaxis in severely injured patients. Insulin (section 18) is included in the light of increasing evidence of improved outcome for severely injured patients with tighter blood glucose control.

Finally, an important mode of pain control in patients with extremity injuries consists of splinting and immobilization. These have been addressed in section 5.8 (Management of extremity injury) and section 5.9 (Management of spinal injury) of these guidelines.

TABLE 12 Pain control and medicines

Facility level

Anaesthesia (WHO EML1 section 1)

Basic GP

Specialist

Tertiary

bupivacaine (or equivalent)

I D

E

E

general anaesthetic (ether, halothane or equivalent)

I D

E

E

ketamine

ID

E

E

lidocaine (or equivalent)

D E

E

E

nitrous oxide

ID

E

E

TABLE 12 Continued

Facility level

Basic

GP

Specialist

Tertiary

oxygen

D

E

E

E

thiopental (or equivalent)

I

D

E

E

diazepam (or equivalent)

D

E

E

E

atropine

D

D

E

E

Pain, fever, inflammation (WHO EML section 2)

morphine (or equivalent)

D

E

E

E

codeine (or equivalent)

D

E

E

E

acetylsalicyclic acid

E

E

E

E

ibuprofen (or equivalent)

D

D

E

E

paracetamol (acetaminophen)

E

E

E

E

Anaphylaxis (WHO EML section 3)

dexamethasone, hydrocortisone (or other equivalent steroid)

D

E

E

E

epinephrine

D

E

E

E

Poisoning (WHO EML section 4)

naloxone

D

E

E

E

Anticonvulsants (WHO EML section 5)

phenobarbital

D

E

E

E

phenytoin

D

E

E

E

magnesium sulphate

D

E

E

E

Infections (WHO EML section 6)

amoxycillin/ampicillin

D

E

E

E

amoxycillin & clavulanic acid (C)2

D

D

D

D

amphotericin

I

D

E

E

benzylpenicillin

D

E

E

E

ceftazidime (C)

I

D

D

D

ceftriaxone (C)

I

D

D

D

chloramphenicol

D

E

E

E

ciprofloxacin (or equivalent)

D

D

E

E

clindamycin (C)

I

D

D

D

cloxacillin (or equivalent)

D

E

E

E

fluconazole (or equivalent)

I

D

E

E

gentamicin (or equivalent)

D

E

E

E

imipenem & cilastin (C)

I

D

D

D

GUIDELINES FOR ESSENTIAL TRAUMA CARE TABLE 12 Continued

Facility level

Basic

GP

Specialist

Tertiary

levofloxacin (C)

I

D

D

D

metronidazole

D

E

E

E

sulfamethoxazole & trimethoprim (or equivalent)

D

E

E

E

Medicines affecting the blood (section 10)

heparin

I

D

E

E

warfarin (or equivalent)

I

D

E

E

Blood products and plasma expanders (WHO EML section 11)

dextran 70, polygeline (or equivalent)

D

D

D

D

Factor IX concentrate (C)

I

D

D

D

factor VIII concentrate (C)

I

D

D

D

Cardiovascular disorders (WHO EML section 12)

dopamine

I

D

D

D

epinephrine (C)

I

D

D

D

Skin diseases: topical applications (WHO EML section 13)

sulfadiazine

D

E

E

E

Antiseptics and disinfectants (WHO EML section 15)

antiseptics: chlorhexidine, ethanol, polyvidone or equivalent

E

E

E

E

disinfectants: chlorine base compound, chloroxylenol, glutaral or equivalent

D

E

E

E

Diuretics (WHO EML section 16)

furosemide (or equivalent)

D

E

E

E

mannitol (C)

D

D

D

D

Gastrointestinal disorders (WHO EML section 17)

aluminium hydroxide

I

E

E

E

Cimetidine (or equivalent)

I

D

E

E

magnesium hydroxide

I

E

E

E

Hormone disorders (WHO EML section 18)

insulin

I

E

E

E

Muscle relaxants (WHO EML section 20)

alcuronium, suxamethonium or equivalent

I

D

E

E

TABLE 12 Continued

Facility level

Basic

GP

Specialist

Tertiary

neostigmine (or equivalent)

I

D

E

E

vecuronium (C)

I

D

D

D

Fluid and electrolyte balance (WHO EML section 26)

glucose solution (5%, 50%)

D

E

E

E

normal saline solution (0.9% isotonic)

D

E

E

E

glucose with sodium chloride (4% glucose, 0.18% NaCl)

D

D

D

D

compound solution of sodium lactate (Ringer's lactate or equivalent)

D

E

E

E

potassium chloride solution

D

D

E

E

Vitamins and minerals (WHO EML section 27)

calcium chloride/gluconate (C)

I

D

D

D

1 EML: WHO's Model list of essential medicines (WHO, 2002)

2 C: WHO's Complementary model list

1 EML: WHO's Model list of essential medicines (WHO, 2002)

2 C: WHO's Complementary model list

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