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This is VAERS ID 455355

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History of Changes from the VAERS Wayback Machine

First Appeared on 5/12/2012

VAERS ID: 455355
VAERS Form:
Age:0.3
Sex:Male
Location:West Virginia
Vaccinated:2012-04-24
Onset:2012-05-04
Submitted:2012-05-10
Entered:2012-05-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4165AB / 1 UN / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVC093AA / 1 UN / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917245 / 1 UN / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41DB273A / 1 - / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Body temperature decreased, Cardiac arrest, Convulsion, Renal failure, Respiratory arrest, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-05-05
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? No
Previous Vaccinations:
Other Medications: Amoxicillin
Current Illness: URI/OM treated 4/20/12 -$g improved 4/24/12; no fever; GATS/ACTS GERD; Nares nl; Lungs nl; TM nl; RTM LR returning; ROM acute
Preexisting Conditions: 37 wk AGA; Apgar 6 - 1, 9 - 5; Frenulectomy 12/29/11; Neonatal screen nl
Allergies:
Diagnostic Lab Data: Seen at ER
CDC 'Split Type':

Write-up: Received shots on 4/24/12 (3pm appointment time). 5/4/12 went down for nap -$g checked in 90 min & not breathing. ER chart received. CPR started at scene 1543. At ER 1553 in triage. Asystole on strip. 1608 temp 96.7. By 1608 pulse without compression, epinephrine drip. Renal failure by next day. No spont respiration. Seizures (+) after event.


Changed on 5/13/2013

VAERS ID: 455355 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:West Virginia
Vaccinated:2012-04-24
Onset:2012-05-04
Submitted:2012-05-10
Entered:2012-05-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4165AB / 1 UN / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVC093AA / 1 UN / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917245 / 1 UN / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41DB273A / 1 - / PO
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41DB273A / 1 - / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Body temperature decreased, Cardiac arrest, Convulsion, Renal failure, Respiratory arrest, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-05-05
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? No
Previous Vaccinations:
Other Medications: Amoxicillin
Current Illness: URI/OM treated 4/20/12 -$g improved 4/24/12; no fever; GATS/ACTS GERD; Nares nl; Lungs nl; TM nl; RTM LR returning; ROM acute
Preexisting Conditions: 37 wk AGA; Apgar 6 - 1, 9 - 5; Frenulectomy 12/29/11; Neonatal screen nl
Allergies:
Diagnostic Lab Data: Seen at ER
CDC 'Split Type':

Write-up: Received shots on 4/24/12 (3pm appointment time). 5/4/12 went down for nap -$g checked in 90 min & not breathing. ER chart received. CPR started at scene 1543. At ER 1553 in triage. Asystole on strip. 1608 temp 96.7. By 1608 pulse without compression, epinephrine drip. Renal failure by next day. No spont respiration. Seizures (+) after event.


Changed on 6/14/2014

VAERS ID: 455355 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:West Virginia
Vaccinated:2012-04-24
Onset:2012-05-04
Submitted:2012-05-10
Entered:2012-05-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4165AB / 1 UN / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVC093AA / 1 UN / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917245 / 1 UN / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41DB273A / 1 - / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Body temperature decreased, Cardiac arrest, Convulsion, Renal failure, Respiratory arrest, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-05-05
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? No
Previous Vaccinations:
Other Medications: Amoxicillin
Current Illness: URI/OM treated 4/20/12 -$g improved 4/24/12; no fever; GATS/ACTS GERD; Nares nl; Lungs nl; TM nl; RTM LR returning; ROM acute
Preexisting Conditions: 37 wk AGA; Apgar 6 - 1, 9 - 5; Frenulectomy 12/29/11; Neonatal screen nl
Allergies:
Diagnostic Lab Data: Seen at ER
CDC 'Split Type':

Write-up: Received shots on 4/24/12 (3pm appointment time). 5/4/12 went down for nap -$g checked in 90 min & not breathing. ER chart received. CPR started at scene 1543. At ER 1553 in triage. Asystole on strip. 1608 temp 96.7. By 1608 pulse without compression, epinephrine drip. Renal failure by next day. No spont respiration. Seizures (+) after event.


Changed on 2/14/2017

VAERS ID: 455355 Before After
VAERS Form:
Age:0.3 0.34
Sex:Male
Location:West Virginia
Vaccinated:2012-04-24
Onset:2012-05-04
Submitted:2012-05-10
Entered:2012-05-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4165AB / 1 UN / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVC093AA / 1 UN / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917245 / 1 UN / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41DB273A / 1 - / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Body temperature decreased, Cardiac arrest, Convulsion, Renal failure, Respiratory arrest, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-05-05
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? No
Previous Vaccinations:
Other Medications: Amoxicillin
Current Illness: URI/OM treated 4/20/12 -$g improved 4/24/12; no fever; GATS/ACTS GERD; Nares nl; Lungs nl; TM nl; RTM LR returning; ROM acute
Preexisting Conditions: 37 wk AGA; Apgar 6 - 1, 9 - 5; Frenulectomy 12/29/11; Neonatal screen nl
Allergies:
Diagnostic Lab Data: Seen at ER
CDC 'Split Type':

Write-up: Received shots on 4/24/12 (3pm appointment time). 5/4/12 went down for nap -$g checked in 90 min & not breathing. ER chart received. CPR started at scene 1543. At ER 1553 in triage. Asystole on strip. 1608 temp 96.7. By 1608 pulse without compression, epinephrine drip. Renal failure by next day. No spont respiration. Seizures (+) after event.


Changed on 9/14/2017

VAERS ID: 455355 Before After
VAERS Form:(blank) 1
Age:0.34
Sex:Male
Location:West Virginia
Vaccinated:2012-04-24
Onset:2012-05-04
Submitted:2012-05-10
Entered:2012-05-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4165AB / 1 2 UN / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVC093AA / 1 2 UN / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917245 / 1 2 UN / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41DB273A / 1 2 - MO / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Body temperature decreased, Cardiac arrest, Convulsion, Renal failure, Respiratory arrest, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-05-05
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? No
Previous Vaccinations:
Other Medications: Amoxicillin
Current Illness: URI/OM treated 4/20/12 -$g improved 4/24/12; no fever; GATS/ACTS GERD; Nares nl; Lungs nl; TM nl; RTM LR returning; ROM acute
Preexisting Conditions: 37 wk AGA; Apgar 6 - 1, 9 - 5; Frenulectomy 12/29/11; Neonatal screen nl
Allergies:
Diagnostic Lab Data: Seen at ER
CDC 'Split Type':

Write-up: Received shots on 4/24/12 (3pm appointment time). 5/4/12 went down for nap -$g checked in 90 min & not breathing. ER chart received. CPR started at scene 1543. At ER 1553 in triage. Asystole on strip. 1608 temp 96.7. By 1608 pulse without compression, epinephrine drip. Renal failure by next day. No spont respiration. Seizures (+) after event.


Changed on 2/14/2018

VAERS ID: 455355 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:West Virginia
Vaccinated:2012-04-24
Onset:2012-05-04
Submitted:2012-05-10
Entered:2012-05-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4165AB / 2 UN / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVC093AA / 2 UN / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917245 / 2 UN / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41DB273A / 2 MO / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Body temperature decreased, Cardiac arrest, Convulsion, Renal failure, Respiratory arrest, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-05-05
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? No
Previous Vaccinations:
Other Medications: Amoxicillin
Current Illness: URI/OM treated 4/20/12 -$g improved 4/24/12; no fever; GATS/ACTS GERD; Nares nl; Lungs nl; TM nl; RTM LR returning; ROM acute
Preexisting Conditions: 37 wk AGA; Apgar 6 - 1, 9 - 5; Frenulectomy 12/29/11; Neonatal screen nl
Allergies:
Diagnostic Lab Data: Seen at ER
CDC 'Split Type':

Write-up: Received shots on 4/24/12 (3pm appointment time). 5/4/12 went down for nap -$g checked in 90 min & not breathing. ER chart received. CPR started at scene 1543. At ER 1553 in triage. Asystole on strip. 1608 temp 96.7. By 1608 pulse without compression, epinephrine drip. Renal failure by next day. No spont respiration. Seizures (+) after event.


Changed on 6/14/2018

VAERS ID: 455355 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:West Virginia
Vaccinated:2012-04-24
Onset:2012-05-04
Submitted:2012-05-10
Entered:2012-05-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4165AB / 2 UN / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVC093AA / 2 UN / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917245 / 2 UN / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41DB273A / 2 MO / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Body temperature decreased, Cardiac arrest, Convulsion, Renal failure, Respiratory arrest, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-05-05
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? No
Previous Vaccinations:
Other Medications: Amoxicillin
Current Illness: URI/OM treated 4/20/12 -$g improved 4/24/12; no fever; GATS/ACTS GERD; Nares nl; Lungs nl; TM nl; RTM LR returning; ROM acute
Preexisting Conditions: 37 wk AGA; Apgar 6 - 1, 9 - 5; Frenulectomy 12/29/11; Neonatal screen nl
Allergies:
Diagnostic Lab Data: Seen at ER
CDC 'Split Type':

Write-up: Received shots on 4/24/12 (3pm appointment time). 5/4/12 went down for nap -$g checked in 90 min & not breathing. ER chart received. CPR started at scene 1543. At ER 1553 in triage. Asystole on strip. 1608 temp 96.7. By 1608 pulse without compression, epinephrine drip. Renal failure by next day. No spont respiration. Seizures (+) after event.


Changed on 8/14/2018

VAERS ID: 455355 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:West Virginia
Vaccinated:2012-04-24
Onset:2012-05-04
Submitted:2012-05-10
Entered:2012-05-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4165AB / 2 UN / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVC093AA / 2 UN / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917245 / 2 UN / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41DB273A / 2 MO / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Body temperature decreased, Cardiac arrest, Convulsion, Renal failure, Respiratory arrest, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-05-05
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? No
Previous Vaccinations:
Other Medications: Amoxicillin
Current Illness: URI/OM treated 4/20/12 -$g improved 4/24/12; no fever; GATS/ACTS GERD; Nares nl; Lungs nl; TM nl; RTM LR returning; ROM acute
Preexisting Conditions: 37 wk AGA; Apgar 6 - 1, 9 - 5; Frenulectomy 12/29/11; Neonatal screen nl
Allergies:
Diagnostic Lab Data: Seen at ER
CDC 'Split Type':

Write-up: Received shots on 4/24/12 (3pm appointment time). 5/4/12 went down for nap -$g checked in 90 min & not breathing. ER chart received. CPR started at scene 1543. At ER 1553 in triage. Asystole on strip. 1608 temp 96.7. By 1608 pulse without compression, epinephrine drip. Renal failure by next day. No spont respiration. Seizures (+) after event.


Changed on 9/14/2018

VAERS ID: 455355 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:West Virginia
Vaccinated:2012-04-24
Onset:2012-05-04
Submitted:2012-05-10
Entered:2012-05-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4165AB / 2 UN / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVC093AA / 2 UN / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917245 / 2 UN / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41DB273A / 2 MO / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Body temperature decreased, Cardiac arrest, Convulsion, Renal failure, Respiratory arrest, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-05-05
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? No
Previous Vaccinations:
Other Medications: Amoxicillin
Current Illness: URI/OM treated 4/20/12 -$g improved 4/24/12; no fever; GATS/ACTS GERD; Nares nl; Lungs nl; TM nl; RTM LR returning; ROM acute
Preexisting Conditions: 37 wk AGA; Apgar 6 - 1, 9 - 5; Frenulectomy 12/29/11; Neonatal screen nl
Allergies:
Diagnostic Lab Data: Seen at ER
CDC 'Split Type':

Write-up: Received shots on 4/24/12 (3pm appointment time). 5/4/12 went down for nap -$g checked in 90 min & not breathing. ER chart received. CPR started at scene 1543. At ER 1553 in triage. Asystole on strip. 1608 temp 96.7. By 1608 pulse without compression, epinephrine drip. Renal failure by next day. No spont respiration. Seizures (+) after event.


Changed on 10/14/2018

VAERS ID: 455355 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:West Virginia
Vaccinated:2012-04-24
Onset:2012-05-04
Submitted:2012-05-10
Entered:2012-05-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4165AB / 2 UN / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVC093AA / 2 UN / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917245 / 2 UN / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41DB273A / 2 MO / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Body temperature decreased, Cardiac arrest, Convulsion, Renal failure, Respiratory arrest, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-05-05
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? No
Previous Vaccinations:
Other Medications: Amoxicillin
Current Illness: URI/OM treated 4/20/12 -$g improved 4/24/12; no fever; GATS/ACTS GERD; Nares nl; Lungs nl; TM nl; RTM LR returning; ROM acute
Preexisting Conditions: 37 wk AGA; Apgar 6 - 1, 9 - 5; Frenulectomy 12/29/11; Neonatal screen nl
Allergies:
Diagnostic Lab Data: Seen at ER
CDC 'Split Type':

Write-up: Received shots on 4/24/12 (3pm appointment time). 5/4/12 went down for nap -$g checked in 90 min & not breathing. ER chart received. CPR started at scene 1543. At ER 1553 in triage. Asystole on strip. 1608 temp 96.7. By 1608 pulse without compression, epinephrine drip. Renal failure by next day. No spont respiration. Seizures (+) after event.


Changed on 12/24/2020

VAERS ID: 455355 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:West Virginia
Vaccinated:2012-04-24
Onset:2012-05-04
Submitted:2012-05-10
Entered:2012-05-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4165AB / 2 UN / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVC093AA / 2 UN / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917245 / 2 UN / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41DB273A / 2 MO / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Body temperature decreased, Cardiac arrest, Convulsion, Renal failure, Respiratory arrest, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-05-05
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? No
Previous Vaccinations:
Other Medications: Amoxicillin
Current Illness: URI/OM treated 4/20/12 -$g improved 4/24/12; no fever; GATS/ACTS GERD; Nares nl; Lungs nl; TM nl; RTM LR returning; ROM acute
Preexisting Conditions: 37 wk AGA; Apgar 6 - 1, 9 - 5; Frenulectomy 12/29/11; Neonatal screen nl
Allergies:
Diagnostic Lab Data: Seen at ER
CDC 'Split Type':

Write-up: Received shots on 4/24/12 (3pm appointment time). 5/4/12 went down for nap -$g checked in 90 min & not breathing. ER chart received. CPR started at scene 1543. At ER 1553 in triage. Asystole on strip. 1608 temp 96.7. By 1608 pulse without compression, epinephrine drip. Renal failure by next day. No spont respiration. Seizures (+) after event.


Changed on 12/30/2020

VAERS ID: 455355 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:West Virginia
Vaccinated:2012-04-24
Onset:2012-05-04
Submitted:2012-05-10
Entered:2012-05-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4165AB / 2 UN / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVC093AA / 2 UN / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917245 / 2 UN / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41DB273A / 2 MO / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Body temperature decreased, Cardiac arrest, Convulsion, Renal failure, Respiratory arrest, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-05-05
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? No
Previous Vaccinations:
Other Medications: Amoxicillin
Current Illness: URI/OM treated 4/20/12 -$g improved 4/24/12; no fever; GATS/ACTS GERD; Nares nl; Lungs nl; TM nl; RTM LR returning; ROM acute
Preexisting Conditions: 37 wk AGA; Apgar 6 - 1, 9 - 5; Frenulectomy 12/29/11; Neonatal screen nl
Allergies:
Diagnostic Lab Data: Seen at ER
CDC 'Split Type':

Write-up: Received shots on 4/24/12 (3pm appointment time). 5/4/12 went down for nap -$g checked in 90 min & not breathing. ER chart received. CPR started at scene 1543. At ER 1553 in triage. Asystole on strip. 1608 temp 96.7. By 1608 pulse without compression, epinephrine drip. Renal failure by next day. No spont respiration. Seizures (+) after event.


Changed on 5/7/2021

VAERS ID: 455355 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:West Virginia
Vaccinated:2012-04-24
Onset:2012-05-04
Submitted:2012-05-10
Entered:2012-05-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4165AB / 2 UN / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVC093AA / 2 UN / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917245 / 2 UN / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41DB273A / 2 MO / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Body temperature decreased, Cardiac arrest, Convulsion, Renal failure, Respiratory arrest, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-05-05
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? No
Previous Vaccinations:
Other Medications: Amoxicillin
Current Illness: URI/OM treated 4/20/12 -$g improved 4/24/12; no fever; GATS/ACTS GERD; Nares nl; Lungs nl; TM nl; RTM LR returning; ROM acute
Preexisting Conditions: 37 wk AGA; Apgar 6 - 1, 9 - 5; Frenulectomy 12/29/11; Neonatal screen nl
Allergies:
Diagnostic Lab Data: Seen at ER
CDC 'Split Type':

Write-up: Received shots on 4/24/12 (3pm appointment time). 5/4/12 went down for nap -$g checked in 90 min & not breathing. ER chart received. CPR started at scene 1543. At ER 1553 in triage. Asystole on strip. 1608 temp 96.7. By 1608 pulse without compression, epinephrine drip. Renal failure by next day. No spont respiration. Seizures (+) after event.


Changed on 5/21/2021

VAERS ID: 455355 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:West Virginia
Vaccinated:2012-04-24
Onset:2012-05-04
Submitted:2012-05-10
Entered:2012-05-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4165AB / 2 UN / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVC093AA / 2 UN / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917245 / 2 UN / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41DB273A / 2 MO / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Body temperature decreased, Cardiac arrest, Convulsion, Renal failure, Respiratory arrest, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-05-05
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? No
Previous Vaccinations:
Other Medications: Amoxicillin
Current Illness: URI/OM treated 4/20/12 -$g improved 4/24/12; no fever; GATS/ACTS GERD; Nares nl; Lungs nl; TM nl; RTM LR returning; ROM acute
Preexisting Conditions: 37 wk AGA; Apgar 6 - 1, 9 - 5; Frenulectomy 12/29/11; Neonatal screen nl
Allergies:
Diagnostic Lab Data: Seen at ER
CDC 'Split Type':

Write-up: Received shots on 4/24/12 (3pm appointment time). 5/4/12 went down for nap -$g checked in 90 min & not breathing. ER chart received. CPR started at scene 1543. At ER 1553 in triage. Asystole on strip. 1608 temp 96.7. By 1608 pulse without compression, epinephrine drip. Renal failure by next day. No spont respiration. Seizures (+) after event.

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