What is the primary cause of death in a patient who suffered a road traffic accident (RTA) with multiple fractures and severe bleeding, received a blood transfusion in the operating room, but still arrested and died?

Primary Cause of Death in Trauma with Multiple Fractures, Severe Bleeding, and Cardiac Arrest Despite Transfusion

The primary cause of death in this patient is uncontrolled hemorrhage leading to irreversible hemorrhagic shock, which progressed to cardiac arrest despite blood transfusion because the underlying bleeding source was not surgically or radiologically controlled in time. 1

Understanding the Lethal Triad and Hemorrhagic Shock Progression

The patient likely died from the combination of:

• Uncontrolled hemorrhage as the primary driver, where mortality increases approximately 1% every 3 minutes when significant internal bleeding remains uncontrolled 2
• Coagulopathy that develops rapidly in trauma patients with massive bleeding, making transfusion alone insufficient without source control 1, 3
• The lethal triad of hypothermia, acidosis, and coagulopathy that becomes irreversible once established, leading to multi-organ failure and cardiac arrest 3, 4

Why Blood Transfusion Alone Failed

Blood transfusion without hemorrhage control does not prevent death in exsanguinating trauma patients. 1

• Patients with obvious bleeding sources and hemorrhagic shock in extremis require immediate bleeding control procedures—transfusion is an adjunct, not the primary treatment 1
• In multiple fractures with severe bleeding (particularly pelvic fractures), ongoing hemorrhage from venous plexuses, fracture surfaces, and arterial sources continues despite transfusion unless mechanical stabilization and/or angioembolization is performed 1
• The European trauma guidelines emphasize that in "agonal patients, death is an imminent risk if the source of bleeding is not rapidly controlled" 1

Critical Pathophysiology Leading to Arrest

The progression to cardiac arrest occurred through:

• Inadequate oxygen delivery to vital organs despite transfusion, as hemorrhagic shock causes critical organ hypoperfusion that rapidly leads to multi-organ failure and death if untreated 4
• Trauma-induced coagulopathy that worsens with ongoing bleeding, creating a vicious cycle where transfused blood products cannot compensate for continued blood loss 1, 3
• Metabolic derangements including severe acidosis (base deficit), hypothermia, hypocalcemia, and hyperkalemia that impair cardiac function and lead to arrest 3, 5

What Should Have Been Done Differently

The patient needed immediate surgical or angiographic bleeding control, not just transfusion. 1

• Hemodynamically unstable patients with multiple fractures and severe bleeding require urgent intervention rather than additional imaging or prolonged resuscitation attempts 1, 2
• For pelvic fractures with ongoing bleeding, concurrent pelvic stabilization (external fixation or pelvic binder) plus angiographic embolization should be implemented immediately 2
• Damage control surgery principles with rapid control of hemorrhage as the primary goal should have been applied 2
• Aortic cross-clamping may be employed as an adjunct in exsanguinating patients to achieve temporary bleeding control while definitive intervention is prepared 1

Common Pitfalls That Lead to This Outcome

• Delaying surgical or radiological intervention in favor of continued resuscitation and transfusion in the operating room without addressing the bleeding source 1, 2
• Failure to recognize that transfusion alone cannot compensate for ongoing massive hemorrhage—source control is paramount 1
• Inadequate recognition of the shock index (heart rate/systolic BP ≥ 0.9-1.0) which predicts massive transfusion needs and should trigger immediate bleeding control procedures 1
• Not implementing massive transfusion protocols with appropriate ratios (1:1:1 of packed red blood cells, fresh frozen plasma, and platelets) while simultaneously pursuing hemorrhage control 3