The patient’s vital signs were stable, and we observed no evidence of bleeding other than bruising around multiple abdominal injection sites. He had taken his last dose of rivaroxaban 3 days before the current presentation. The injected dalteparin was left over from a previous prescription for 15 000 units daily. Previously, he had switched among several anti-coagulants owing to intolerance or breakthrough thrombosis, including warfarin, various preparations of low-molecular-weight heparin (LMWH) and, most recently, rivaroxaban. The patient’s medical history included depression, heterozygous factor V Leiden mutation and recurrent venous thromboembolism (VTE). Serial monitoring of LMWH anti-Xa levels or activated partial thromboplastin time or both may help to guide therapy.Ī 42-year-old man presented to the emergency department 2 hours after self-injecting 225 000 units of dalteparin (15 prefilled 15 000-unit vials) with intent to self-harm.
Protamine sulfate partially reverses the anticoagulant effect of LMWH and may prevent bleeding from LMWH overdose. Bleeding in low-molecular-weight heparin (LMWH) overdose is unpredictable and may develop insidiously in deep tissues such as retroperitoneal and intramuscular spaces.
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