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From the 7/16/2021 release of VAERS data:

This is VAERS ID 950441



Case Details

VAERS ID: 950441 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-15
Onset:2021-01-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1283 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Adjusted calcium, Alanine aminotransferase increased, Albumin globulin ratio, Anion gap, Aspartate aminotransferase increased, Band neutrophil percentage decreased, Basophil count normal, Basophil percentage, Blood albumin normal, Blood alkaline phosphatase increased, Blood bilirubin normal, Blood calcium normal, Blood chloride decreased, Blood creatinine normal, Blood glucose normal, Blood magnesium increased, Blood potassium decreased, Blood sodium decreased, Blood urea nitrogen/creatinine ratio, Blood urea normal, Carbon dioxide normal, Cardiac arrest, Death, Differential white blood cell count abnormal, Echocardiogram abnormal, Eosinophil count normal, Eosinophil percentage, Full blood count abnormal, Globulin, Glomerular filtration rate, Haematocrit normal, Haemoglobin normal, Immature granulocyte percentage increased, Lymphocyte count normal, Lymphocyte percentage increased, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin normal, Mean cell volume increased, Mean platelet volume increased, Mechanical ventilation, Metabolic function test abnormal, Monocyte count normal, Monocyte percentage, Neutrophil count normal, Neutrophil percentage decreased, Neutrophil toxic granulation present, Platelet count normal, Protein total normal, Pupil fixed, Red blood cell count normal, Red blood cell nucleated morphology present, Red cell distribution width normal, Resuscitation, Unresponsive to stimuli, Ventricular fibrillation, White blood cell count normal
SMQs:, Torsade de pointes/QT prolongation (broad), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Agranulocytosis (broad), Haematopoietic leukopenia (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Myelodysplastic syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Hypokalaemia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   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: Hydrochlorothiazide Toprol XL spironolactone prasugrel furosemide Vit D3 albuterol inhaler sildenafil aspirin 81mg Crestor nitroglycerin SL singulair testosterone gel levothyroxine
Current Illness: Chronic systolic heart failure Coronary artery disease involving native coronary artery of native heart without angina pectoris
Preexisting Conditions: Chronic systolic heart failure Coronary artery disease involving native coronary artery of native heart without angina pectoris lower extremity edema
Allergies: Walnuts
Diagnostic Lab Data: 1/15/2021 CBC WITH AUTO DIFF - Abnormal Result Value ? WBC 8.8 ? ? RBC 5.1 ? ? Hgb 15.7 ? ? Hematocrit 49.5 ? ? MCV 97.1 (*) ? ? MCH 30.8 ? ? MCHC 31.7 (*) ? ? Red Cell Distribution Width 14.3 ? ? Platelets 173 ? ? Mean Platelet Volume 11.4 ? COMPREHENSIVE METABOLIC PANEL - Abnormal ? Glucose 167 (*) ? ? Blood Urea Nitrogen 14 ? ? Creat, Serum 1.2 ? ? Sodium 134 (*) ? ? Potassium 3.1 (*) ? ? Chloride 93 (*) ? ? CO2 25 ? ? Anion Gap 16 (*) ? ? Calcium 9.9 ? ? Total Bilirubin 1.0 ? ? Alkaline Phosphatase 126 ? ? AST 62 ? ? ALT (SGPT) 41 ? ? Total Protein 6.7 ? ? Albumin 3.6 ? ? Globulin, Total 3.1 ? ? A/G Ratio 1.16 ? ? BUN/Creatinine Ratio 11.67 ? ? Corrected Calcium 10.2 ? ? eGFR $g60.00 ? ? Narrative: ? Specimen slightly hemolyzed, K, AST & ALK may be affected. ? MAGNESIUM - Abnormal ? Magnesium 2.4 (*) ? ? Narrative: ? Specimen slightly hemolyzed, Mg may be affected. ? DIFFERENTIAL, MANUAL - Abnormal ? Total Counted 100 ? ? Nucleated Red Blood Cell 1.0 ? ? Neutrophils Relative 45 ? ? Band Neutrophils Relative 0 ? ? Lymphocytes Relative 46 ? ? Monocytes Relative 5 ? ? Eosinophils Relative 1 ? ? Basophils Relative 1 ? ? Immature Granulocytes Relative 2 ? ? Neutrophils Absolute 4.0 ? ? Lymphocytes Absolute 4.0 (*) ? ? Monocytes Absolute 0.4 ? ? Eosinophils Absolute 0.1 ? ? Basophils Absolute 0.1 ? ? Toxic Granulation Present ? ? Platelet Estimate Normal ? ? ?
CDC Split Type:

Write-up: Pt had witnessed arrest by wife. Pt wife started CPR and called EMS. CPR started at 15:12. Continued by EMS. Pt arrived to medical center asystole with CRP in progress and ventilated via igel device. He was in refractory ventricular fibrillation and continued CPR for a total of 1 hour. At that point, we checked a bedside ultrasound which showed his heart at a standstill. He was unresponsive to verbal and tactile stimulus and had fixed unreactive pupils. He was pronounced at 16:13.


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