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This is VAERS ID 1116594

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1116594
VAERS Form:2
Age:72.0
Sex:Female
Location:Georgia
Vaccinated:2021-03-04
Onset:2021-03-04
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / UNK - / SYR

Administered by: Pharmacy      Purchased by: ??
Symptoms: Cardiac arrest, Death, Hypoxia, Respiratory arrest, Respiratory distress, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Warfarin
Current Illness: Unknown
Preexisting Conditions:
Allergies: No known allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient called EMS from for respiratory distress. EMS arrived, noted severe distress and hypoxia. Patient transported to Hospital Emergency Dept. Patient deteriorated to respiratory arrest and cardiac arrest. Per ED note, after 30 minutes of aggressive resuscitation (including approximately 19 minutes in the ED), no ROSC was achieved. Patient expired


Changed on 5/7/2021

VAERS ID: 1116594 Before After
VAERS Form:2
Age:72.0
Sex:Female
Location:Georgia
Vaccinated:2021-03-04
Onset:2021-03-04
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / UNK - / SYR

Administered by: Pharmacy      Purchased by: ??
Symptoms: Cardiac arrest, Death, Hypoxia, Respiratory arrest, Respiratory distress, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Warfarin
Current Illness: Unknown
Preexisting Conditions:
Allergies: No known allergies allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient called EMS from for respiratory distress. EMS arrived, noted severe distress and hypoxia. Patient transported to Hospital Emergency Dept. Patient deteriorated to respiratory arrest and cardiac arrest. Per ED note, after 30 minutes of aggressive resuscitation (including approximately 19 minutes in the ED), no ROSC was achieved. Patient expired


Changed on 5/14/2021

VAERS ID: 1116594 Before After
VAERS Form:2
Age:72.0
Sex:Female
Location:Georgia
Vaccinated:2021-03-04
Onset:2021-03-04
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / UNK - / SYR

Administered by: Pharmacy      Purchased by: ??
Symptoms: Cardiac arrest, Death, Hypoxia, Respiratory arrest, Respiratory distress, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Warfarin
Current Illness: Unknown
Preexisting Conditions:
Allergies: No known allergies allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient called EMS from for respiratory distress. EMS arrived, noted severe distress and hypoxia. Patient transported to Hospital Emergency Dept. Patient deteriorated to respiratory arrest and cardiac arrest. Per ED note, after 30 minutes of aggressive resuscitation (including approximately 19 minutes in the ED), no ROSC was achieved. Patient expired

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1116594&WAYBACKHISTORY=ON

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