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

Primary Cause of Death: Severe Bleeding (Hemorrhagic Shock)

The primary cause of death in this patient is the severe bleeding itself, not the multiple fractures or the cardiac arrest—the cardiac arrest was the terminal event resulting from uncontrolled hemorrhage. 1

Understanding the Causal Chain

The critical distinction here is between the underlying cause versus the mechanism of death:

• Severe bleeding (hemorrhagic shock) is the underlying pathophysiologic process that killed this patient 1
• Cardiac arrest is merely the terminal rhythm—the final common pathway through which death occurred 2
• Multiple fractures are the anatomic injuries that caused the bleeding 1

Why Bleeding is the Primary Cause

Hemorrhage is the leading cause of death in patients with major trauma and multiple fractures, accounting for the majority of preventable trauma deaths. 1 The European trauma guidelines explicitly state that "haemorrhage is the leading cause of death in patients with major pelvic fractures" and that mortality in patients with severe pelvic ring disruptions and hemodynamic instability remains 30-45%. 1

Blood transfusion without hemorrhage source control does not prevent death in exsanguinating trauma patients—transfusion is an adjunct, not the primary treatment. 3 The guidelines emphasize that "in agonal patients, death is an imminent risk if the source of bleeding is not rapidly controlled." 3

The Pathophysiology of Death

Trauma-induced coagulopathy develops rapidly with massive bleeding, creating a vicious cycle where transfused blood products cannot compensate for continued blood loss. 3 This patient likely developed:

• Progressive hypovolemic shock from ongoing hemorrhage 1
• Trauma-induced coagulopathy making bleeding worse despite transfusion 1, 3
• The "lethal triad" of hypothermia, acidosis, and coagulopathy 4
• Terminal cardiac arrest from profound shock 2

Hypovolemia from hemorrhagic shock is the most significant cause of early death in trauma cardiac arrest. 2

What Should Have Been Done

The patient needed immediate surgical or angiographic bleeding control, not just transfusion. 3 The Critical Care guidelines state that "patients with obvious bleeding sources and hemorrhagic shock in extremis require immediate bleeding control procedures." 3

Specific interventions that were likely missing:

• Immediate surgical bleeding control through damage control surgery with rapid hemorrhage control 3
• Pelvic stabilization (external fixation or pelvic binder) if pelvic fractures were present 3
• Angiographic embolization for ongoing arterial bleeding from fracture sites 1, 3
• Aortic cross-clamping as a temporizing measure in the exsanguinating patient 1, 3

Critical Pitfall in This Case

The fatal error was delaying surgical or radiological intervention in favor of continued resuscitation and transfusion without addressing the bleeding source. 3 The guidelines warn that "transfusion alone cannot compensate for ongoing massive hemorrhage—source control is paramount." 3

Mortality increases approximately 1% every 3 minutes of delay in controlling significant internal hemorrhage. 3

Documentation Perspective

For death certification purposes, the proper sequence would be:

• Immediate cause of death: Cardiac arrest 2
• Due to: Hemorrhagic shock 1
• Due to: Multiple fractures from road traffic accident 1

However, the primary/underlying cause that set the fatal sequence in motion is the severe bleeding from the multiple fractures, not the cardiac arrest which was merely the terminal event. 1, 2