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

Objectives: Evaluation of diagnostic and therapeutic work-up in multiply in jured 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 ri ng instability. In patients with persistent or massive hemorrhage, laparoto my and pelvic packing were performed. Consecutive measurements of blood lac tate 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 d uring the first 5.4 +/-3.3 hours from arrival, one patient because of septi c 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 compare d with survivors without laparotomy (2.8 +/-1.1 mmol/l). In contrast, hemog lobin (7.0 +/-2.6 g/dl versus 7.9 +/-2.21 g/dl) and hematocrit (21.4 +/-6.4 percent versus 23.2 +/-6.8 percent) were similar in both groups. In patien ts who died during the first hours after admission, lactate levels were ele vated (8.6 +/-2.5 mmol/l) compared with survivors (4.2 +/-1.8 mmol/l) and i ncreased further. Conclusions: Sequential measurements of blood lactate levels during the ear ly 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 co ntrol of severe hemorrhage in multiply injured patients with pelvic ring di sruption.