| VAERS ID: |
918518 (history) |
| Form: |
Version 2.0 |
| Age: |
50.0 |
| Sex: |
Female |
| Location: |
Nebraska |
| Vaccinated: | 2020-12-31 |
| Onset: | 2020-12-31 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-04 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011L20A / 1 |
UN / IM |
Administered by: Private Purchased by: ?
Symptoms: Autopsy,
Cardio-respiratory arrest,
Death,
Resuscitation,
Syncope
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), Acute central respiratory depression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2020-12-31
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: To be determined
Current Illness: To be determined
Preexisting Conditions: To be determined
Allergies: To be determined
Diagnostic Lab Data: Autopsy being performed
CDC Split Type:
Write-up: syncopal episode - arrested - CPR - death |
