In a road‑traffic‑accident patient with multiple fractures and massive hemorrhage who received blood transfusion but then arrested and died, what is the primary cause of death: multiple fractures, cardiac arrest, or severe bleeding?

Primary Cause of Death: Severe Bleeding (Hemorrhage)

The primary cause of death in this case is severe bleeding (option C), as uncontrolled post-traumatic hemorrhage is the leading cause of potentially preventable death among trauma patients, and cardiac arrest in this context represents the terminal event resulting from exsanguination rather than a primary cardiac etiology. 1

Understanding the Pathophysiologic Sequence

The clinical scenario describes a cascade where severe bleeding leads to hemorrhagic shock, which ultimately culminates in cardiac arrest and death. This distinction is critical for death certification and understanding preventable mortality:

• Hemorrhage is the proximate cause: Uncontrolled post-traumatic bleeding accounts for the leading cause of early preventable trauma deaths, with most deaths occurring within the first 6 hours after injury. 1, 2

• Cardiac arrest is the mechanism, not the cause: The cardiac arrest represents the final common pathway of cardiovascular collapse from severe hypovolemia and tissue hypoxia, not a primary cardiac event. 3, 4

• Multiple fractures are the anatomic injury: While the fractures created the bleeding sources (venous plexuses, cancellous bone surfaces, potential arterial injuries), they are the underlying injury pattern rather than the direct cause of death. 1

Why Blood Transfusion Alone Failed

The critical error in this case was likely the failure to achieve hemorrhage control despite transfusion:

• Transfusion without source control is futile: Blood transfusion alone cannot prevent death in exsanguinating trauma patients—immediate bleeding control procedures are paramount, with transfusion serving only as an adjunct. 5

• The vicious cycle of ongoing hemorrhage: Trauma-induced coagulopathy worsens with continued bleeding, creating a situation where transfused blood products cannot compensate for ongoing blood loss without mechanical or surgical hemorrhage control. 5

• Time-critical nature of intervention: Mortality increases approximately 1% every 3 minutes of delay in controlling significant internal hemorrhage, and patients presenting with hemorrhagic shock and an identified bleeding source require immediate bleeding control procedures unless initial resuscitation measures are successful. 5, 6

What Should Have Been Done

The patient needed immediate hemorrhage control interventions, not just transfusion in the operating room:

• For multiple fractures with severe bleeding: Mechanical stabilization (pelvic binder for pelvic fractures, external fixation for long bones) and/or angiographic embolization should have been performed urgently. 5, 6

• Damage control surgery principles: If surgical bleeding sources were identified, rapid control of hemorrhage should have been the primary goal rather than prolonged resuscitation attempts. 5

• Recognition of futility: In "agonal patients, death is an imminent risk if the source of bleeding is not rapidly controlled"—continued transfusion without addressing the bleeding source represents a critical management failure. 5

Common Pitfall in This Case

The most likely error was delaying surgical or radiological intervention in favor of continued resuscitation and transfusion without addressing the bleeding source. 5 This represents a failure to recognize that:

• Hemodynamically unstable patients with multiple fractures and severe bleeding require urgent intervention rather than additional imaging or prolonged resuscitation attempts. 5

• The shock index (heart rate/systolic BP ≥ 0.9-1.0) predicts massive transfusion needs and should trigger immediate bleeding control procedures. 5

Correct Death Certification

For medicolegal and quality improvement purposes:

• Primary cause of death: Severe bleeding/hemorrhage from multiple fractures
• Mechanism of death: Cardiac arrest secondary to hemorrhagic shock
• Underlying cause: Multiple fractures from road traffic accident

This distinction matters because hemorrhagic death from trauma is potentially preventable with timely hemorrhage control, whereas listing "cardiac arrest" as the primary cause obscures the preventable nature of the death and hinders trauma system quality improvement efforts. 1, 2