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From the 1/14/2022 release of VAERS data:

This is VAERS ID 1865389

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Case Details

VAERS ID: 1865389 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Female  
Location: Georgia  
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-11-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Cardiac dysfunction, Chemotherapy, Death, Electrocardiogram Q waves, Electrocardiogram T wave peaked, Heart rate increased, Hypoxia, Livedo reticularis, Mechanical ventilation, Multiple organ dysfunction syndrome, Oxygen saturation decreased, Poor peripheral circulation, Pulmonary haemorrhage, Resuscitation, Thrombocytopenia
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Malignancy related therapeutic and diagnostic procedures (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Sepsis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Bactrim, dexamethasone, Ketorolac, Vanc, sodium chloride
Current Illness: ALL, hypertension, obesity, Type 2 Diabetes, Cdiff
Preexisting Conditions: ALL phase DI of treatment, hypertension, Diabetes, obesity
Allergies: NKA
Diagnostic Lab Data: Pt expired 11/11/21 (Continued) despite vasopressor support. She was given a dose of bicarbonate with some brief improvement in saturations to 70s and increased heart rate but subsequently became asystolic and CPR was started. She was given epi x 2 doses as well as a dose of bicarbonate and was hand ventilated; there was significant blood backing up into her ETT. Parents at the bedside requested cessation of resuscitation efforts at that point and the patient was pronounced dead at 2036 on 11/11/21. The doctor of the heme/onc service made aware of the patient''s death; she had been at the bedside earlier in the day and involved with the conversations regarding the patient''s decline.
CDC Split Type:

Write-up: Patient with progressive hypoxemia throughout the day despite multiple changes in ventilator settings/modes. HFOV discussed with family, but functional oscillator not available and was awaiting arrival of donor oscillator. She is not a candidate for ECMO due to pulmonary hemorrhage and thrombocytopenia with recent chemotherapy as well as BMI (morbidly obese). Trial on nitric oxide performed with minimal improvement (sats increased from 60% to 65-68%). She was noted to have increasing peaked T waves as well as development of Q waves concerning for hyperkalemia and worsening cardiac function consistent with multiorgan failure; perfusion was quite poor with mottled extremities and difficult to palpate central pulse

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