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

This is VAERS ID 1225016



Case Details

VAERS ID: 1225016 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-04-06
Onset:2021-04-06
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER9480 / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Electrocardiogram
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? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-04-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Name: ECG; Result Unstructured Data: Test Result:unknown result
CDC Split Type: DEPFIZER INC2021398798

Write-up: The lethal outcome with asystole 20:20h; This is a spontaneous report received from a non-contactable physician downloaded from the Agency Regulatory Authority-WEB. The Regulatory Authority report number is DE-PEI-202100031681. A 78-year-old male patient received BNT162B2 (COMIRNATY, lot number: ER9480 and expiration date not reported), via an unspecified route of administration on 06Apr2021 as 0.3 mL, single for COVID-19 immunisation. The patient''s medical history and concomitant medications were not reported. On 06Apr2021 20:20 the patient experienced lethal outcome with asystole. ECG (Electrocardiography), Cardiopulmonary Resuscitation through Ramus diagonalis. The patient died on 06Apr2021. It was not reported if an autopsy was performed. The event was assessed as serious (death, life threatening). Relatedness of drug to reaction/event by Regulatory Authority was D. Unclassifiable. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: The lethal outcome with asystole


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