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This is VAERS ID 416930

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2011

VAERS ID: 416930
VAERS Form:
Age:32.0
Sex:Male
Location:Delaware
Vaccinated:2010-11-02
Onset:2010-11-25
Submitted:2011-02-16
Entered:2011-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR C3486AA / 0 LA / IM

Administered by: Public      Purchased by: Private
Symptoms: Cardioversion, Convulsion, Death, Hypoxic-ischaemic encephalopathy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: seizure resulting in defribrilation resulting in anoxic brain injury. treated at Hospital.


Changed on 4/13/2011

VAERS ID: 416930 Before After
VAERS Form:
Age:32.0
Sex:Male
Location:Delaware
Vaccinated:2010-11-02
Onset:2010-11-25
Submitted:2011-02-16
Entered:2011-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR C3486AA / 0 LA / IM

Administered by: Public      Purchased by: Private
Symptoms: Anion gap increased, Blood calcium decreased, Blood creatine phosphokinase increased, Blood creatine phosphokinase MB increased, Blood creatinine increased, Blood gases abnormal, Blood glucose increased, Blood lactic acid increased, Carbon dioxide decreased, Cardiac arrest, Cardioversion, Chest X-ray abnormal, Convulsion, Death, Depressed level of consciousness, Dyspepsia, Electrocardiogram abnormal, Electroencephalogram abnormal, Heart sounds abnormal, Intensive care, Left ventricular failure, Loss of consciousness, Multi-organ failure, Nuclear magnetic resonance imaging brain abnormal, Posturing, Renal failure acute, Unresponsive to stimuli, Ventilation/perfusion scan abnormal, Ventricular fibrillation, Blood phosphorus decreased, Computerised tomogram abdomen abnormal, Troponin T increased, Echocardiogram abnormal, Hypoxic-ischaemic encephalopathy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: seizure resulting in defribrilation resulting in anoxic brain injury. treated at Hospital.


Changed on 5/13/2011

VAERS ID: 416930 Before After
VAERS Form:
Age:32.0
Sex:Male
Location:Delaware
Vaccinated:2010-11-02
Onset:2010-11-25
Submitted:2011-02-16
Entered:2011-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR C3486AA / 0 LA / IM

Administered by: Public      Purchased by: Private
Symptoms: Anion gap increased, Blood calcium decreased, Blood creatine phosphokinase increased, Blood creatine phosphokinase MB increased, Blood creatinine increased, Blood gases abnormal, Blood glucose increased, Blood lactic acid increased, Carbon dioxide decreased, Cardiac arrest, Cardioversion, Chest X-ray abnormal, Convulsion, Death, Depressed level of consciousness, Dyspepsia, Electrocardiogram abnormal, Electroencephalogram abnormal, Heart sounds abnormal, Intensive care, Left ventricular failure, Loss of consciousness, Multi-organ failure, Nuclear magnetic resonance imaging brain abnormal, Posturing, Renal failure acute, Unresponsive to stimuli, Ventilation/perfusion scan abnormal, Ventricular fibrillation, Blood phosphorus decreased, Computerised tomogram abdomen abnormal, Troponin T increased, Echocardiogram abnormal, Hypoxic-ischaemic encephalopathy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: seizure resulting in defribrilation resulting in anoxic brain injury. treated at Hospital.


Changed on 9/14/2017

VAERS ID: 416930 Before After
VAERS Form:(blank) 1
Age:32.0
Sex:Male
Location:Delaware
Vaccinated:2010-11-02
Onset:2010-11-25
Submitted:2011-02-16
Entered:2011-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR C3486AA / 0 1 LA / IM

Administered by: Public      Purchased by: Private
Symptoms: Cardioversion, Convulsion, Death, Hypoxic-ischaemic encephalopathy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: seizure resulting in defribrilation resulting in anoxic brain injury. treated at Hospital.


Changed on 2/14/2018

VAERS ID: 416930 Before After
VAERS Form:1
Age:32.0
Sex:Male
Location:Delaware
Vaccinated:2010-11-02
Onset:2010-11-25
Submitted:2011-02-16
Entered:2011-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR C3486AA / 1 LA / IM

Administered by: Public      Purchased by: Private
Symptoms: Cardioversion, Convulsion, Death, Hypoxic-ischaemic encephalopathy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: seizure resulting in defribrilation resulting in anoxic brain injury. treated at Hospital.


Changed on 6/14/2018

VAERS ID: 416930 Before After
VAERS Form:1
Age:32.0
Sex:Male
Location:Delaware
Vaccinated:2010-11-02
Onset:2010-11-25
Submitted:2011-02-16
Entered:2011-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR C3486AA / 1 LA / IM

Administered by: Public      Purchased by: Private
Symptoms: Cardioversion, Convulsion, Death, Hypoxic-ischaemic encephalopathy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: seizure resulting in defribrilation resulting in anoxic brain injury. treated at Hospital.


Changed on 8/14/2018

VAERS ID: 416930 Before After
VAERS Form:1
Age:32.0
Sex:Male
Location:Delaware
Vaccinated:2010-11-02
Onset:2010-11-25
Submitted:2011-02-16
Entered:2011-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR C3486AA / 1 LA / IM

Administered by: Public      Purchased by: Private
Symptoms: Cardioversion, Convulsion, Death, Hypoxic-ischaemic encephalopathy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: seizure resulting in defribrilation resulting in anoxic brain injury. treated at Hospital.


Changed on 9/14/2018

VAERS ID: 416930 Before After
VAERS Form:1
Age:32.0
Sex:Male
Location:Delaware
Vaccinated:2010-11-02
Onset:2010-11-25
Submitted:2011-02-16
Entered:2011-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR C3486AA / 1 LA / IM

Administered by: Public      Purchased by: Private
Symptoms: Cardioversion, Convulsion, Death, Hypoxic-ischaemic encephalopathy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: seizure resulting in defribrilation resulting in anoxic brain injury. treated at Hospital.


Changed on 10/14/2018

VAERS ID: 416930 Before After
VAERS Form:1
Age:32.0
Sex:Male
Location:Delaware
Vaccinated:2010-11-02
Onset:2010-11-25
Submitted:2011-02-16
Entered:2011-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR C3486AA / 1 LA / IM

Administered by: Public      Purchased by: Private
Symptoms: Cardioversion, Convulsion, Death, Hypoxic-ischaemic encephalopathy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: seizure resulting in defribrilation resulting in anoxic brain injury. treated at Hospital.


Changed on 12/24/2020

VAERS ID: 416930 Before After
VAERS Form:1
Age:32.0
Sex:Male
Location:Delaware
Vaccinated:2010-11-02
Onset:2010-11-25
Submitted:2011-02-16
Entered:2011-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR C3486AA / 1 LA / IM

Administered by: Public      Purchased by: Private
Symptoms: Cardioversion, Convulsion, Death, Hypoxic-ischaemic encephalopathy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: seizure resulting in defribrilation resulting in anoxic brain injury. treated at Hospital.


Changed on 12/30/2020

VAERS ID: 416930 Before After
VAERS Form:1
Age:32.0
Sex:Male
Location:Delaware
Vaccinated:2010-11-02
Onset:2010-11-25
Submitted:2011-02-16
Entered:2011-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR C3486AA / 1 LA / IM

Administered by: Public      Purchased by: Private
Symptoms: Cardioversion, Convulsion, Death, Hypoxic-ischaemic encephalopathy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: seizure resulting in defribrilation resulting in anoxic brain injury. treated at Hospital.


Changed on 5/7/2021

VAERS ID: 416930 Before After
VAERS Form:1
Age:32.0
Sex:Male
Location:Delaware
Vaccinated:2010-11-02
Onset:2010-11-25
Submitted:2011-02-16
Entered:2011-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR C3486AA / 1 LA / IM

Administered by: Public      Purchased by: Private
Symptoms: Cardioversion, Convulsion, Death, Hypoxic-ischaemic encephalopathy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: seizure resulting in defribrilation resulting in anoxic brain injury. treated at Hospital.


Changed on 5/14/2021

VAERS ID: 416930 Before After
VAERS Form:1
Age:32.0
Sex:Male
Location:Delaware
Vaccinated:2010-11-02
Onset:2010-11-25
Submitted:2011-02-16
Entered:2011-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR C3486AA / 1 LA / IM

Administered by: Public      Purchased by: Private
Symptoms: Cardioversion, Convulsion, Death, Hypoxic-ischaemic encephalopathy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: seizure resulting in defribrilation resulting in anoxic brain injury. treated at Hospital.

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