It fits! (Intelligence transfer: From images to solutions) massive abdominal ecchymosis and hematoma due to local injection of enoxaparin

A 67-year-old female was admitted to the hospital with chest pain and short ness of air. One month previously, she had sustained an anterior myocardial infarction complicated by the development of a left ventricular aneurysm. She was taking warfarin at the time of admission and the International Norm alized Ratio (INR) was 1.8. She was in congestive heart failure thought sec ondary to unstable angina pectoris and was given weight-adjusted subcutaneo us enoxaparin injected subcutaneously in the abdominal area. The following morning she had a massive abdominal hematoma (Fig. 1). With only two doses of enoxaparin, the INR went to 30.3 and the hematocrit fell from 36.5% to 2 6.2%, requiring transfusion with fresh frozen plasma and packed red blood c ells. The bleeding time and hematocrit stabilized. She was discharged 5 day s after admission.