Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption

OBJECTIVES Evaluation of diagnostic and therapeutic workup in multiply injured patients with pelvic ring disruption and hemorrhagic shock. DESIGN Prospective study. PATIENTS Twenty consecutive multiply injured patients (ISS: 41.2 +/- 15.3 points) with pelvic ring disruption and hemorrhagic shock. INTERVENTION A C-clamp was used for primary stabilization of the pelvic ring instability. In patients with persistent or massive hemorrhage, laparotomy and pelvic packing were performed. Consecutive measurements of blood lactate levels during the early period after injury. MAIN OUTCOME MEASUREMENTS Lactate, mortality. RESULTS A C-clamp was applied in all patients within 57.4 +/- 30.6 minutes of arrival. Fourteen patients underwent laparotomy with pelvic packing for control of hemorrhage, three patients additional resuscitation thoracotomy (aortic clamping: n = 2). Four patients died of exsanguinating hemorrhage during the first 5.4 +/- 3.3 hours from arrival, one patient because of septic multi-organ failure twenty-three days after injury (total mortality: 5/20; 25 percent). Lactate levels at admission were elevated in all patients (5.1 +/- 2.6 mmol/l). Increased blood lactate levels (4.8 +/- 1.7 mmol/l) (+71 percent; p < 0.05) were observed in survivors undergoing laparotomy compared with survivors without laparotomy (2.8 +/- 1.1 mmol/l). In contrast, hemoglobin (7.0 +/- 2.6 g/dl versus 7.9 +/- 2.2 g/dl) and hematocrit (21.4 +/- 6.4 percent versus 23.2 +/- 6.8 percent) were similar in both groups. In patients who died during the first hours after admission, lactate levels were elevated (8.6 +/- 2.5 mmol/l) compared with survivors (4.2 +/- 1.8 mmol/l) and increased further. CONCLUSIONS Sequential measurements of blood lactate levels during the early period after injury may provide a more rapid and reliable estimation of true severity of hemorrhage than routinely used parameters. Pelvic packing in addition to pelvic ring fixation with a C-clamp allows for effective control of severe hemorrhage in multiply injured patients with pelvic ring disruption.