VAERS ID: |
1225942 (history) |
Form: |
Version 2.0 |
Age: |
16.0 |
Sex: |
Female |
Location: |
Wisconsin |
Vaccinated: | 2021-03-19 |
Onset: | 2021-03-28 |
Days after vaccination: | 9 |
Submitted: |
0000-00-00 |
Entered: |
2021-04-18 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
UNKNOWN / 1 |
- / - |
Administered by: Unknown Purchased by: ? Symptoms: Cardiac arrest,
Death,
Laboratory test,
Lung assist device therapy,
Oral contraception,
Pulmonary embolism,
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), Embolic and thrombotic events, venous (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: 2021-03-30
Days after onset: 2
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: Reported to be on Drospirenone-Ethinyl Estradiol 3-0.02 MG per tab Current Illness: Preexisting Conditions: Allergies: Diagnostic Lab Data: CDC Split Type:
Write-up: Patient was a 16yr female who received Pfizer vaccine 3/19/21 at vaccine clinic and presented with ongoing CPR to the ED 3/28/21 after cardiac arrest at home. Patient placed on ECMO and imaging revealed bilateral large pulmonary embolism as likely etiology of arrest. Risk factors included oral contraceptive use. Labs have since confirmed absence of Factor V leiden or prothrombin gene mutation. Patient declared dead by neurologic criteria 3/30/21. |