VAERS ID: |
1498080 (history) |
Form: |
Version 2.0 |
Age: |
15.0 |
Sex: |
Male |
Location: |
New York |
Vaccinated: | 2021-07-18 |
Onset: | 2021-07-22 |
Days after vaccination: | 4 |
Submitted: |
0000-00-00 |
Entered: |
2021-07-23 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EW0196 / 1 |
LA / IM |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EW0198 / 2 |
LA / IM |
Administered by: Pharmacy Purchased by: ? Symptoms: Resuscitation,
Syncope,
Ventricular tachycardia SMQs:, Torsade de pointes/QT prolongation (narrow), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-07-22
Days after onset: 0
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
Extended hospital stay? No Previous Vaccinations: Other Medications: Lopressor 25mg BID Current Illness: Diagnosed May 2021 hypertrophic cardiomyopathy Preexisting Conditions: Diagnosed May 2021 hypertrophic cardiomyopathy Allergies: unknown Diagnostic Lab Data: none at this time CDC Split Type:
Write-up: 7/22/2021 Child collapsed on soccer field while playing soccer at a local camp. CPR was initiated immediately. EMS arrived and found patient in vtac. Shock x 5. ACLS, intubation attempted. Transported to Medical Center. Patient had covid in April 2021. Dx in May 2021 hypertrophic cardiomyopathy. Started on lopressor 25mg BID. Patient had reported to parents that he had not recently taken his medications. Patient had his second covid vaccine on Sunday 7/18/2021. |