Fatal retroperitoneal hematoma after enoxaparin administration in a patient with paroxysmal atrial flutter

A case of fatal retroperitoneal hematoma that developed after enoxaparin administration in a woman with paroxysmal atrial flutter and chest pain is reported.

A 63-year-old, 74-kg, African-American woman arrived at the emergency department with a 24-hour history of severe, nonexertional, substernal chest pain that radiated down her left arm. An electrocardiograph with continuous telemetry showed new-onset paroxysmal atrial flutter without ST-segment elevation. She was treated with aspirin 325 mg, metoprolol 25 mg, and subcutaneous enoxaparin 80 mg (0.93 mg/kg) every 12 hours. On hospital day 2, she was given warfarin 5 mg daily and continued on enoxaparin. Approximately 36 hours after admission, she became acutely hypotensive and developed tachycardia. She was transferred to the medical intensive care unit and intubated for respiratory arrest. Soon after, she was found to be in asystole and, despite multiple rounds of standard advanced cardiac life support and infusion of blood products, the patient expired 3 hours after the initial emergency resuscitation code was called. A postmortem examination revealed a large, noncommunicating, retroperitoneal hematoma located posterior to the right kidney as the cause of death.

A 63-year-old African-American woman with a 24-hour history of severe, nonexertional chest pain and new-onset paroxysmal atrial flutter without ST-segment elevation was treated with enoxaparin and subsequently died of a fatal spontaneous retroperitoneal hematoma.