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

This is VAERS ID 1085478



Case Details

VAERS ID: 1085478 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-02-24
Onset:2021-03-08
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 2 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Brain injury, Cardioversion, Computerised tomogram, Critical illness, Echocardiogram abnormal, Fatigue, Intensive care, Laboratory test, Malaise, Pulmonary contusion, Pulmonary haemorrhage, Resuscitation, Rib fracture, Splenic rupture, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Accidents and injuries (narrow), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Osteoporosis/osteopenia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: PCN
Diagnostic Lab Data: Multiple CT''s, labs
CDC Split Type:

Write-up: Patient has been feeling fatigued since the vaccine. On 3/8 he went to play Hockey, first time since pandemic started. He reported feeling to his friends that he felt unwell and left the ice. He was found dead, CPR started, EMS called-$g had shockable rhythm (VF), shocked 10 times pre-hospital. Brought to Hospital ER and placed on VA ECMO. He is currently in the ICU setting; echo suggests possible MI but formal cath pending. Has anoxic brain injury, splenic laceration, pulmonary hemorrhage/contusions, rib fractures all related to CPR (received over an hour prior to ECMO placement). Patient may ultimately expire, he is critically ill.


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