Session VIII - Pelvis

Sunday, October 24, 1999 Session VIII, Paper #59, 8:23 a.m.

Control of Severe Hemorrhage in Multiply Injured Patients with Pelvic Ring Disruption Using C-Clamp and Pelvic Packing

Wolfgang Klaus Ertel, MD; Marius Keel, MD; Andreas Platz, MD; Otmar Trentz, MD, Department of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland

Purpose: Pelvic disruption in combination with multiple injuries is associated with high mortality. Despite improved protocols for shock treatment and acute reduction and fixation of the displaced pelvis using external fixation devices, mortality of those patients has recently been reported between 33% and 58%. This study evaluates the effectiveness of a combination of C-clamp and pelvic/abdominal packing in multiply injured patients with pelvic ring disruption and severe hemorrhage. Moreover, the use of lactate blood levels for rapid recognition of "hidden" shock was studied.

Methods: From 1/97 to 12/98 14 consecutive patients (mean age: 43.1±15.7 years; [mean ± SD]; ISS: 37.2±14.9 points; APACHE II: 19.1±4.7 points) in extremis (12 units of blood/2hr or necessity of catecholamines) were enrolled. Associated injuries were head (n=6; AIS: 3.0±1.5 points), chest (n=8; AIS: 3.8±0.7 points), abdomen (n=5; AIS: 4.2±0.4 points), spine (n=3; 2.0±0.0 points), and extremities (n=11; AIS: 3.1±0.5 points). Pelvic injuries were type C fractures (n=12; C1: n=4; C2: n=1; C3: n=7) and type B fractures in 2 patients (B1: n=1;B2: n=1) All patients were treated according to ATLS guidelines. For fixation of posterior ring disruption C-clamp was used in all patients. In patients with obvious signs of torrential hemorrhage crash laparotomy and pelvic packing were carried out.

Results: C-clamp was applied in all patients within 50.9±27.7 minutes (range 5 ­ 85 min) after arrival. Eight patients (57%) underwent crash laparotomy with pelvic packing for control of hemorrhage, 2 patients (14%) additional resuscitation thoracotomy (aortic clamping n=1). Three of the laparotomized patients (38%) developed abdominal compartment syndrome followed by decompressive laparotomy. Packing was retrieved after 28.8±5.1 hours on average, definitive stabilization of pelvic ring injuries was accomplished after 2.5±2.9 days (range 1 ­ 11 days). Mean blood substitution during hospital stay was 54.6±26.9 units of packed red blood cells (range 5 ­ 89 units). Two patients died due to pelvic hemorrhage during the first 5.5±2.6 hours upon arrival, one patient because of septic MOF 23 days after injury (total mortality: 3/14; 21%). Lactate levels obtained at admission were elevated in all patients (4.6±2.7 mmol/L). However, in patients that required pelvic packing (5.6±2.9 mmol/L), lactate levels obtained at admission were markedly increased by 70% compared to patients without packing (3.3±1.8 mmol/L). In contrast, hemoglobin (6.7±2.1 g/dL versus 7.6±2.4 g/dL; -12%) and hematocrit (20.1±6.2 versus 22.5±7.2; -11%) early after admission were similar in both groups. While lactate levels normalized in all survivors, increased concentrations were observed in the two patients dying from pelvic hemorrhage.

Discussion: Pelvic packing in addition to posterior ring fixation with C-clamp reduced mortality of multiply injured patients with severe pelvic injury admitted in extremis compared to previous studies. Furthermore, measurements of arterial lactate levels early after admission may provide a more rapid and reliable estimation of the true severity of hemorrhagic shock, which may not be correctly jugded by routine clinical parameters (hemoglobin, hematocrit).

Conclusion: Rapid diagnosis of "hidden" hemorrhagic shock and aggressive management of bleeding control using a combination of external fixation and pelvic/abdominal packing further reduces mortality in multiply injured patients with associated pelvic ring disruption.