Differential Diagnosis for Sudden Death after Dalteparin Administration and Coffee Ground Vomiting

Single Most Likely Diagnosis

• Gastrointestinal Bleeding leading to Hemorrhagic Shock: The administration of dalteparin, a low molecular weight heparin, increases the risk of bleeding. The coffee ground vomit, indicative of upper gastrointestinal bleeding, followed by rapid deterioration and death, suggests a massive bleed leading to hemorrhagic shock.

Other Likely Diagnoses

• Peptic Ulcer Disease: The coffee ground vomit suggests upper GI bleeding, which could be due to a peptic ulcer. The use of anticoagulants like dalteparin could exacerbate the bleeding.
• Esophageal Variceal Hemorrhage: Although less common without a known history of liver disease, the sudden onset of severe upper GI bleeding could be due to esophageal varices, especially if there was underlying liver disease or portal hypertension.
• Acute Myocardial Infarction: While the primary symptom presented is GI bleeding, the sudden death could also be attributed to a cardiac event, especially if the patient had underlying cardiac risk factors.

Do Not Miss Diagnoses

• Pulmonary Embolism: Despite being on dalteparin, which is used to prevent thromboembolic events, the possibility of a pulmonary embolism cannot be entirely ruled out, especially if the dalteparin was started recently or if there were issues with dosing or administration.
• Aortic Dissection: A catastrophic cardiac event that could present with sudden death, and while less directly related to the GI symptoms, it's a diagnosis that would be critical to consider due to its high mortality rate.
• Intracranial Hemorrhage: Although the symptoms suggest a GI source of bleeding, an intracranial hemorrhage could also present with sudden deterioration and death, especially if the patient was on anticoagulation.

Rare Diagnoses

• Heparin-Induced Thrombocytopenia (HIT): A rare but serious side effect of heparin therapy, which could paradoxically increase the risk of thrombosis and bleeding.
• Thrombotic Thrombocytopenic Purpura (TTP): A rare blood disorder characterized by the formation of blood clots in small blood vessels throughout the body, which could lead to sudden death.
• Fat Embolism Syndrome: Although more commonly associated with long bone fractures, it could be considered in the differential diagnosis of sudden death with unclear etiology, especially if there were recent traumatic events.