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|History of Changes from the VAERS Wayback Machine|
|Vaccination / Manufacturer||Lot / Dose||Site / Route|
|COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA||039K20A / 1||LA / IM|
Administered by: Other Purchased by: ??
Symptoms: Cardiac arrest, Cardio-respiratory arrest, Chest X-ray abnormal, Cyanosis, Death, Lung infiltration, Pulse absent, Respiratory arrest, Resuscitation, Unresponsive to stimuli, Autopsy, Lung opacity, SARS-CoV-2 test negative
Life Threatening? No
Birth Defect? No
Permanent Disability? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Diagnostic Lab Data: Covid negative: 12/27/20, 1/20/21, 1/25/21 Covid Negative 1/11/21
CDC 'Split Type':
Write-up: UNKNOWN/ASYTOLE Narrative: Please refer to section 6. 68y/o male with h/o severe peripheral vascular disease with previous left AKA 2/3/20, s/p bilateral bypasses in the past. Pt recently underwent right AKA on 1/12/21. Per Hospital remote data 1/10/21 pt c/o shortness of breath, CXR demonstrated right lower lobe opacity & left basilar infiltrate. Pt s/p $g10 days emperic IV abx. Moderna vaccine 0.5ml IM was administered via left deltoid on 1/22/21 around 16:21. On 1/23/21@05:14 code blue was called as pt found to be unresponsive, breathless and pulseless, facial cyanosis noted, CPR started immediately.Pt found to be in asystole. ACLS guideline followed but no return of spontaneous circulation, At 05:32 pt remained pulseless and breathless and was pronounced. Autopsy currently pending.
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