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This is VAERS ID 1404913

History of Changes from the VAERS Wayback Machine

First Appeared on 7/23/2021

VAERS ID: 1404913
VAERS Form:2
Age:101.0
Sex:Male
Location:Foreign
Vaccinated:2021-06-01
Onset:2021-06-01
Submitted:0000-00-00
Entered:2021-06-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA4597 / 1 - / -

Administered by: Other      Purchased by: ??
Symptoms: Altered state of consciousness, Body temperature, Hypotension, Pallor, Pulse absent, Shock, Blood pressure measurement

Life Threatening? No
Birth Defect? No
Died? No
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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Vasovagal reaction
Allergies:
Diagnostic Lab Data: Test Date: 202106; Test Name: blood pressure; Result Unstructured Data: Test Result:low; Test Date: 20210601; Test Name: body temperature; Result Unstructured Data: Test Result:36.7 Centigrade; Comments: before vaccination
CDC 'Split Type': JPPFIZER INC2021644107

Write-up: shock; Consciousness disturbed; Pulse impalpable; Pallor facial; low blood pressure; This is a spontaneous report from a contactable physician received from the Agency Regulatory Authority. Regulatory authority report number is v21110911. The patient was a 101-year male. Body temperature before vaccination was 36.7 degrees Centigrade on 01Jun2021. The patient received antihypertensive drugs within 1 month of vaccination. On 01Jun2021, at 11:21, the patient received the first dose of BNT162B2 (COMIRNATY, Lot number FA4597, Expiration date 31Aug2021) via an unspecified route of administration as a single dose for COVID-19 immunization. Medical history included vasovagal reaction. On 01Jun2021, at 11:35 (14 minutes after the vaccination), the patient experienced consciousness disturbed, shock, pallor facial, pulse impalpable. The course of the event was as follows: Fourteen minutes after the vaccination, the patient''s family claimed that he or she tried to get the patients attention, but the patient did not respond. For the patient''s consciousness disturbed, pallor facial, pulse impalpable, it was interpreted as a state of shock. The patient was treated with recumbent position with lower extremities elevated and vital statistics etc. were carried out. It was reported his breathing was stable. The patient''s level of consciousness improved afterwards, and due to low blood pressure, route keep (as reported),the patient was transferred to the emergency room. The outcome of events was unknown. The reporting physician classified the event the causality between the event and BNT162B2 as un-assessable. Other possible cause(s) of the event such as any other diseases was Vascular vagal neurological reflex.

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