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This is VAERS ID 104094

Case Details

VAERS ID: 104094 (history)  
Form: Version 1.0  
Age: 80.0  
Sex: Male  
Location: Connecticut  
Vaccinated:1997-10-28
Onset:1997-10-28
   Days after vaccination:0
Submitted: 1997-10-30
   Days after onset:2
Entered: 1997-10-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3337GB / 3 LA / IM

Administered by: Public       Purchased by: Public
Symptoms: Cardiac arrest, Malaise
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1997-10-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: diabetes, others not known
Allergies:
Diagnostic Lab Data: BP was taken @ clu clinic as a routine service offered to pt 130/66;
CDC Split Type: CT9711

Write-up: pt c/o not feeling well while in car w/wife;EMS was called when arrived pt was in cardiac arrest;attempts to revive failed was transported to hosp ER states COD listed on ER record as cardiac arrest;


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