VAERS ID: |
940866 (history) |
Form: |
Version 2.0 |
Age: |
75.0 |
Sex: |
Male |
Location: |
South Carolina |
Vaccinated: | 2021-01-07 |
Onset: | 2021-01-09 |
Days after vaccination: | 2 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-13 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011L20A / 1 |
- / IM |
Administered by: Other Purchased by: ? Symptoms: Abnormal behaviour,
Cardiac arrest,
Cardio-respiratory arrest,
Death,
Pulse absent,
Resuscitation SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (broad), Cardiomyopathy (broad), Respiratory failure (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-09
Days after onset: 0
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations: Other Medications: Amlodipine, ASA, Atorvastatin, Baclofen, Risperidone, Levothyr Current Illness: None Preexisting Conditions: Hypothyroidism, Bipolar, Profound ID, HTN, Osteopenia, dysphagia, aphasia, TBI as a young adult,Muscle spasm, Hernia Allergies: Loxapine, Thioridazine Diagnostic Lab Data: CDC Split Type:
Write-up: Patient was found "acting abnormal" on 1/9/2021 at 1215. VS HR 20-30''s. EMS activated. EMS arrived and patient was found pulseless in PEA/ asystole, CPR and ACLS initiated and then transported to the MC. Unsuccessful resuscitation and expired on 1/09/2021 at 1348. Clinical impression Cardiopulmonary arrest. |