| VAERS ID: |
1420762 (history) |
| Form: |
Version 2.0 |
| Age: |
17.0 |
| Sex: |
Female |
| Location: |
Unknown |
| Vaccinated: | 2021-06-17 |
| Onset: | 2021-06-23 |
| Days after vaccination: | 6 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-06-23 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / UNK |
- / - |
Administered by: Private Purchased by: ?
Symptoms: Autopsy,
Cardiac arrest
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), Respiratory failure (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-06-23
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: Vienva 0.1-20 mg-mcg per tablet
Current Illness: No.
Preexisting Conditions: Obesity, Family history of clotting disorder (her workup with negative), and depression.
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:
Write-up: Cardiac arrest without resuscitation. Unknown cause of cardiac arrest. Awaiting autopsy report. |
