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This is VAERS ID 114925

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 114925
VAERS Form:
Age:0.2
Sex:Male
Location:Michigan
Vaccinated:1998-09-23
Onset:1998-09-25
Submitted:1998-10-07
Entered:1998-10-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: ACEL-IMUNE / LEDERLE 453844 / 0 RL / IM
HIBV: HIBTITER / LEDERLE(PRAXIS) M240RK / 0 LL / IM
IPV: POLIOVAX / CONNAUGHT LTD N10351 / 0 LL / SC

Administered by: Private      Purchased by: Unknown
Symptoms: AGITATION, APNEA, DYSPNEA, ANEMIA, ALKALOSIS RESP

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-09-26
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE but was 36wk SGA infant
Allergies:
Diagnostic Lab Data: hgb 3.0;bld PH 6.5;NA140;cl 113;plts 91;K+ 7.0;co2 6.5;
CDC 'Split Type':

Write-up: pt recv vax 23SEP98 & was fussy 25SEP98;26SEP98 early hr of AM pt noted to be gasping w/eyes deviated;unsuccessful full resuscitation on immed arrival @ ER;pt was in cardiorespiratory arrest;


Changed on 12/8/2009

VAERS ID: 114925 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Michigan
Vaccinated:1998-09-23
Onset:1998-09-25
Submitted:1998-10-07
Entered:1998-10-15 1998-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: ACEL-IMUNE DTAP (ACEL-IMUNE) / LEDERLE LEDERLE LABORATORIES 453844 / 0 RL / IM
HIBV: HIBTITER HIB (HIBTITER) / LEDERLE(PRAXIS) LEDERLE PRAXSIS M240RK / 0 LL / IM
IPV: POLIOVAX POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD CONNAUGHT LTD. N10351 / 0 LL / SC

Administered by: Private      Purchased by: Unknown Private
Symptoms: Agitation, Anaemia, Apnoea, Cardiac arrest, Dyspnoea, Laboratory test abnormal, Respiratory alkalosis, Gaze palsy, AGITATION, APNEA, DYSPNEA, ANEMIA, ALKALOSIS RESP

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-09-26
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE but was 36wk SGA infant
Allergies:
Diagnostic Lab Data: hgb 3.0;bld PH 6.5;NA140;cl 113;plts 91;K+ 7.0;co2 6.5;
CDC 'Split Type':

Write-up: pt recv vax 23SEP98 & was fussy 25SEP98;26SEP98 early hr of AM pt noted to be gasping w/eyes deviated;unsuccessful full resuscitation on immed arrival @ ER;pt was in cardiorespiratory arrest;


Changed on 5/14/2017

VAERS ID: 114925 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Michigan
Vaccinated:1998-09-23
Onset:1998-09-25
Submitted:1998-10-07
Entered:1998-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 453844 / 0 RL / IM
HIBV: HIB (HIBTITER) / LEDERLE PRAXSIS PFIZER/WYETH M240RK / 0 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N10351 / 0 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Agitation, Anaemia, Apnoea, Cardiac arrest, Dyspnoea, Laboratory test abnormal, Respiratory alkalosis, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-09-26
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE but was 36wk SGA infant
Allergies:
Diagnostic Lab Data: hgb 3.0;bld PH 6.5;NA140;cl 113;plts 91;K+ 7.0;co2 6.5;
CDC 'Split Type':

Write-up: pt recv vax 23SEP98 & was fussy 25SEP98;26SEP98 early hr of AM pt noted to be gasping w/eyes deviated;unsuccessful full resuscitation on immed arrival @ ER;pt was in cardiorespiratory arrest;


Changed on 9/14/2017

VAERS ID: 114925 Before After
VAERS Form:(blank) 1
Age:0.2
Sex:Male
Location:Michigan
Vaccinated:1998-09-23
Onset:1998-09-25
Submitted:1998-10-07
Entered:1998-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 453844 / 0 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M240RK / 0 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N10351 / 0 1 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Agitation, Anaemia, Apnoea, Cardiac arrest, Dyspnoea, Laboratory test abnormal, Respiratory alkalosis, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-09-26
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE but was 36wk SGA infant
Allergies:
Diagnostic Lab Data: hgb 3.0;bld PH 6.5;NA140;cl 113;plts 91;K+ 7.0;co2 6.5;
CDC 'Split Type':

Write-up: pt recv vax 23SEP98 & was fussy 25SEP98;26SEP98 early hr of AM pt noted to be gasping w/eyes deviated;unsuccessful full resuscitation on immed arrival @ ER;pt was in cardiorespiratory arrest;


Changed on 2/14/2018

VAERS ID: 114925 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Michigan
Vaccinated:1998-09-23
Onset:1998-09-25
Submitted:1998-10-07
Entered:1998-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 453844 / 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M240RK / 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N10351 / 1 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Agitation, Anaemia, Apnoea, Cardiac arrest, Dyspnoea, Laboratory test abnormal, Respiratory alkalosis, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-09-26
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE but was 36wk SGA infant
Allergies:
Diagnostic Lab Data: hgb 3.0;bld PH 6.5;NA140;cl 113;plts 91;K+ 7.0;co2 6.5;
CDC 'Split Type':

Write-up: pt recv vax 23SEP98 & was fussy 25SEP98;26SEP98 early hr of AM pt noted to be gasping w/eyes deviated;unsuccessful full resuscitation on immed arrival @ ER;pt was in cardiorespiratory arrest;


Changed on 6/14/2018

VAERS ID: 114925 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Michigan
Vaccinated:1998-09-23
Onset:1998-09-25
Submitted:1998-10-07
Entered:1998-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 453844 / 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M240RK / 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N10351 / 1 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Agitation, Anaemia, Apnoea, Cardiac arrest, Dyspnoea, Laboratory test abnormal, Respiratory alkalosis, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-09-26
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE but was 36wk SGA infant
Allergies:
Diagnostic Lab Data: hgb 3.0;bld PH 6.5;NA140;cl 113;plts 91;K+ 7.0;co2 6.5;
CDC 'Split Type':

Write-up: pt recv vax 23SEP98 & was fussy 25SEP98;26SEP98 early hr of AM pt noted to be gasping w/eyes deviated;unsuccessful full resuscitation on immed arrival @ ER;pt was in cardiorespiratory arrest;


Changed on 8/14/2018

VAERS ID: 114925 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Michigan
Vaccinated:1998-09-23
Onset:1998-09-25
Submitted:1998-10-07
Entered:1998-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 453844 / 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M240RK / 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N10351 / 1 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Agitation, Anaemia, Apnoea, Cardiac arrest, Dyspnoea, Laboratory test abnormal, Respiratory alkalosis, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-09-26
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE but was 36wk SGA infant
Allergies:
Diagnostic Lab Data: hgb 3.0;bld PH 6.5;NA140;cl 113;plts 91;K+ 7.0;co2 6.5;
CDC 'Split Type':

Write-up: pt recv vax 23SEP98 & was fussy 25SEP98;26SEP98 early hr of AM pt noted to be gasping w/eyes deviated;unsuccessful full resuscitation on immed arrival @ ER;pt was in cardiorespiratory arrest;


Changed on 9/14/2018

VAERS ID: 114925 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Michigan
Vaccinated:1998-09-23
Onset:1998-09-25
Submitted:1998-10-07
Entered:1998-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 453844 / 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M240RK / 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N10351 / 1 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Agitation, Anaemia, Apnoea, Cardiac arrest, Dyspnoea, Laboratory test abnormal, Respiratory alkalosis, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-09-26
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE but was 36wk SGA infant
Allergies:
Diagnostic Lab Data: hgb 3.0;bld PH 6.5;NA140;cl 113;plts 91;K+ 7.0;co2 6.5;
CDC 'Split Type':

Write-up: pt recv vax 23SEP98 & was fussy 25SEP98;26SEP98 early hr of AM pt noted to be gasping w/eyes deviated;unsuccessful full resuscitation on immed arrival @ ER;pt was in cardiorespiratory arrest;


Changed on 10/14/2018

VAERS ID: 114925 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Michigan
Vaccinated:1998-09-23
Onset:1998-09-25
Submitted:1998-10-07
Entered:1998-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 453844 / 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M240RK / 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N10351 / 1 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Agitation, Anaemia, Apnoea, Cardiac arrest, Dyspnoea, Laboratory test abnormal, Respiratory alkalosis, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-09-26
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE but was 36wk SGA infant
Allergies:
Diagnostic Lab Data: hgb 3.0;bld PH 6.5;NA140;cl 113;plts 91;K+ 7.0;co2 6.5;
CDC 'Split Type':

Write-up: pt recv vax 23SEP98 & was fussy 25SEP98;26SEP98 early hr of AM pt noted to be gasping w/eyes deviated;unsuccessful full resuscitation on immed arrival @ ER;pt was in cardiorespiratory arrest;

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=114925&WAYBACKHISTORY=ON


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