Control of Severe Hemorrhage Using C-Clamp and Pelvic Packing in Multiply Injured Patients With Pelvic Ring Disruption Wolfgang Ertel, Marius Keel, Karim Eid, Andreas Platz, and Otmar Trentz Division of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland 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 laparoto- my with pelvic packing for control of hemorrhage, three pa- tients 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 hemat- ocrit (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) com- pared 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. Key Words: Pelvic injury, Hemorrhage, Diagnostics, Lactate, Therapeutic, External fixation, C-clamp. The incidence of pelvic trauma increased over the last decade because of a rising number of high-speed acci- dents and suicide attempts. Isolated pelvic injuries inde- pendent of their severity reveal a low mortality rate (1.2 percent during the last ten years at our institution) (22). In contrast, pelvic ring disruption associated with mul- tiple injuries results in a high mortality rate, between 30 and 58 percent (13,20,26). Exsanguinating hemorrhage has been identified as the major cause of death during the first 24 hours after trauma. The assessment of severity and dynamics of bleeding represents a serious problem in those patients and is the crucial hallmark for survival during the early period after injury. Young patients are able to compen- sate severe blood loss over several hours without signifi- cant changes of arterial blood pressure, central venous pressure, hemoglobin, or hematocrit (5). This may lead to underestimation of the true hemodynamic status and may have fatal consequences. Previous studies of critically ill and severely injured patients have suggested that the ability to clear lactate to normal levels correlates with the true state of hemor- rhagic shock and consequently with the probability of survival (1,6,16,23). Pathophysiologically, lactate pro- duction is increased in the case of decreased pyruvate oxidation during tissue hypoxia. The amount of lactate produced is believed to correlate with the total oxygen debt, which is dependent on the magnitude of hypoper- fusion and the severity of hemorrhagic shock (16). Therefore, blood lactate levels seem to better correlate with hypovolemia-induced tissue hypoperfusion and lo- cal oxygen debt than hemoglobin and hematocrit. The emergency management of multiple injured pa- tients with pelvic ring disruption and severe hemorrhage Accepted September 29, 2000. Address correspondence and reprint requests to Wolfgang Ertel, M.D., FACS, Division of Trauma Surgery, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland. Presented at the 15th Annual Meeting of the Orthopaedic Trauma Association, Charlotte, NC, 1999. No financial support of this project has occurred. The authors have received nothing of value. This manuscript does not contain information about medical de- vices. Journal of Orthopaedic Trauma Vol. 15, No. 7, pp. 468–474 © 2001 Lippincott Williams & Wilkins, Inc., Philadelphia 468