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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1038527



Case Details

VAERS ID: 1038527 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: South Dakota  
Vaccinated:2021-02-17
Onset:2021-02-17
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Death, Dyspnoea, Endotracheal intubation, Myoclonus, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unsure. Possibly the following from hospital EHR: albuterol sulfate 90 mcg/actuation inhalation 2 times daily PRN amlodipine besylate 10 mg oral Daily aspirin 81 mg oral Daily atorvastatin calcium 40 mg oral Daily carvedilol 6.25 mg oral 2
Current Illness: Arthritis hands Cardiovascular disease dyslipidemia Chronic bronchitis COPD (chronic obstructive pulmonary disease) Coronary artery disease History of transfusion Hypertension Myocardial infarction stent Peripheral vascular disease Psychiatric illness "feels depressed" on ocassion Renal artery stenosis TIA (transient ischemic attack) "short spurts" of tingling on face Urge incontinence of urine
Preexisting Conditions: Arthritis hands Cardiovascular disease dyslipidemia Chronic bronchitis COPD (chronic obstructive pulmonary disease) Coronary artery disease History of transfusion Hypertension Myocardial infarction stent Peripheral vascular disease Psychiatric illness "feels depressed" on ocassion Renal artery stenosis TIA (transient ischemic attack) "short spurts" of tingling on face Urge incontinence of urine
Allergies: epinephrine, penicillin, procaine per EHR
Diagnostic Lab Data:
CDC Split Type:

Write-up: Per EMS/Hospital report patient had difficulty breathing and cardiac arrest with prolonged CPR (greater than 45 mins in the ER) who was resuscitated. Family subsequently arrived including son and daughter and all family members were in the ER room are in agreement that patient would not want further aggressive cares given her extremely poor prognosis in light of chronic debilitation with numerous medical issues and now a very long period of CPR. Hospital Course After updating family they stated patient would not want further aggressive cares given her grim prognosis and chronic severe and debilitating medical issues. She continued to have myoclonic jerking. She was extubated to comfort cares in the ER and did not pass immediately therefore brought to a room. She received comfort cares and passed away at 0450 with family present.


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