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This is VAERS ID 455522

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History of Changes from the VAERS Wayback Machine

First Appeared on 6/13/2012

VAERS ID: 455522
VAERS Form:
Age:67.0
Sex:Male
Location:Ohio
Vaccinated:2012-02-29
Onset:2012-03-07
Submitted:2012-05-14
Entered:2012-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR CA0300AA / 0 LA / IM

Administered by: Unknown      Purchased by: Private
Symptoms: Cyanosis, Death, Fall, Intensive care, Nervous system disorder, Pulse absent, Resuscitation, Ventricular tachycardia, Endotracheal intubation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2012-03-11
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lipitor, ECBASA, Diltiazem CD, HCTZ, albuterol
Current Illness:
Preexisting Conditions: Hypertension, IHSS, Bradycardia, Hypercholesterolemia, Allergic Rhinitis, Asthma
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt returned from arduous bike ride, took long time in bathroom, wife entered, pt started to speak, turned blue and fell to floor. CPR attempted, EMS took to ER where pulseless. Ventricular tachycardia found. Intubated, CCU care, minimal brain activity, died on 4th day.


Changed on 6/14/2014

VAERS ID: 455522 Before After
VAERS Form:
Age:67.0
Sex:Male
Location:Ohio
Vaccinated:2012-02-29
Onset:2012-03-07
Submitted:2012-05-14
Entered:2012-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR CA0300AA / 0 LA / IM

Administered by: Unknown      Purchased by: Private
Symptoms: Cyanosis, Death, Fall, Intensive care, Nervous system disorder, Pulse absent, Resuscitation, Ventricular tachycardia, Endotracheal intubation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2012-03-11
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lipitor, ECBASA, Diltiazem CD, HCTZ, albuterol
Current Illness:
Preexisting Conditions: Hypertension, IHSS, Bradycardia, Hypercholesterolemia, Allergic Rhinitis, Asthma
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt returned from arduous bike ride, took long time in bathroom, wife entered, pt started to speak, turned blue and fell to floor. CPR attempted, EMS took to ER where pulseless. Ventricular tachycardia found. Intubated, CCU care, minimal brain activity, died on 4th day.


Changed on 4/14/2017

VAERS ID: 455522 Before After
VAERS Form:
Age:67.0
Sex:Male
Location:Ohio
Vaccinated:2012-02-29
Onset:2012-03-07
Submitted:2012-05-14
Entered:2012-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR CA0300AA / 0 LA / IM

Administered by: Unknown      Purchased by: Private
Symptoms: Cyanosis, Death, Fall, Intensive care, Nervous system disorder, Pulse absent, Resuscitation, Ventricular tachycardia, Endotracheal intubation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2012-03-11
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lipitor, ECBASA, Diltiazem CD, HCTZ, albuterol
Current Illness:
Preexisting Conditions: Hypertension, IHSS, Bradycardia, Hypercholesterolemia, Allergic Rhinitis, Asthma
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt returned from arduous bike ride, took long time in bathroom, wife entered, pt started to speak, turned blue and fell to floor. CPR attempted, EMS took to ER where pulseless. Ventricular tachycardia found. Intubated, CCU care, minimal brain activity, died on 4th day.


Changed on 9/14/2017

VAERS ID: 455522 Before After
VAERS Form:(blank) 1
Age:67.0
Sex:Male
Location:Ohio
Vaccinated:2012-02-29
Onset:2012-03-07
Submitted:2012-05-14
Entered:2012-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR CA0300AA / 0 1 LA / IM

Administered by: Unknown      Purchased by: Private
Symptoms: Cyanosis, Death, Fall, Intensive care, Nervous system disorder, Pulse absent, Resuscitation, Ventricular tachycardia, Endotracheal intubation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2012-03-11
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lipitor, ECBASA, Diltiazem CD, HCTZ, albuterol
Current Illness:
Preexisting Conditions: Hypertension, IHSS, Bradycardia, Hypercholesterolemia, Allergic Rhinitis, Asthma
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt returned from arduous bike ride, took long time in bathroom, wife entered, pt started to speak, turned blue and fell to floor. CPR attempted, EMS took to ER where pulseless. Ventricular tachycardia found. Intubated, CCU care, minimal brain activity, died on 4th day.


Changed on 2/14/2018

VAERS ID: 455522 Before After
VAERS Form:1
Age:67.0
Sex:Male
Location:Ohio
Vaccinated:2012-02-29
Onset:2012-03-07
Submitted:2012-05-14
Entered:2012-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR CA0300AA / 1 LA / IM

Administered by: Unknown      Purchased by: Private
Symptoms: Cyanosis, Death, Fall, Intensive care, Nervous system disorder, Pulse absent, Resuscitation, Ventricular tachycardia, Endotracheal intubation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2012-03-11
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lipitor, ECBASA, Diltiazem CD, HCTZ, albuterol
Current Illness:
Preexisting Conditions: Hypertension, IHSS, Bradycardia, Hypercholesterolemia, Allergic Rhinitis, Asthma
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt returned from arduous bike ride, took long time in bathroom, wife entered, pt started to speak, turned blue and fell to floor. CPR attempted, EMS took to ER where pulseless. Ventricular tachycardia found. Intubated, CCU care, minimal brain activity, died on 4th day.


Changed on 6/14/2018

VAERS ID: 455522 Before After
VAERS Form:1
Age:67.0
Sex:Male
Location:Ohio
Vaccinated:2012-02-29
Onset:2012-03-07
Submitted:2012-05-14
Entered:2012-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR CA0300AA / 1 LA / IM

Administered by: Unknown      Purchased by: Private
Symptoms: Cyanosis, Death, Fall, Intensive care, Nervous system disorder, Pulse absent, Resuscitation, Ventricular tachycardia, Endotracheal intubation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2012-03-11
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lipitor, ECBASA, Diltiazem CD, HCTZ, albuterol
Current Illness:
Preexisting Conditions: Hypertension, IHSS, Bradycardia, Hypercholesterolemia, Allergic Rhinitis, Asthma
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt returned from arduous bike ride, took long time in bathroom, wife entered, pt started to speak, turned blue and fell to floor. CPR attempted, EMS took to ER where pulseless. Ventricular tachycardia found. Intubated, CCU care, minimal brain activity, died on 4th day.


Changed on 8/14/2018

VAERS ID: 455522 Before After
VAERS Form:1
Age:67.0
Sex:Male
Location:Ohio
Vaccinated:2012-02-29
Onset:2012-03-07
Submitted:2012-05-14
Entered:2012-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR CA0300AA / 1 LA / IM

Administered by: Unknown      Purchased by: Private
Symptoms: Cyanosis, Death, Fall, Intensive care, Nervous system disorder, Pulse absent, Resuscitation, Ventricular tachycardia, Endotracheal intubation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2012-03-11
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lipitor, ECBASA, Diltiazem CD, HCTZ, albuterol
Current Illness:
Preexisting Conditions: Hypertension, IHSS, Bradycardia, Hypercholesterolemia, Allergic Rhinitis, Asthma
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt returned from arduous bike ride, took long time in bathroom, wife entered, pt started to speak, turned blue and fell to floor. CPR attempted, EMS took to ER where pulseless. Ventricular tachycardia found. Intubated, CCU care, minimal brain activity, died on 4th day.


Changed on 9/14/2018

VAERS ID: 455522 Before After
VAERS Form:1
Age:67.0
Sex:Male
Location:Ohio
Vaccinated:2012-02-29
Onset:2012-03-07
Submitted:2012-05-14
Entered:2012-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR CA0300AA / 1 LA / IM

Administered by: Unknown      Purchased by: Private
Symptoms: Cyanosis, Death, Fall, Intensive care, Nervous system disorder, Pulse absent, Resuscitation, Ventricular tachycardia, Endotracheal intubation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2012-03-11
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lipitor, ECBASA, Diltiazem CD, HCTZ, albuterol
Current Illness:
Preexisting Conditions: Hypertension, IHSS, Bradycardia, Hypercholesterolemia, Allergic Rhinitis, Asthma
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt returned from arduous bike ride, took long time in bathroom, wife entered, pt started to speak, turned blue and fell to floor. CPR attempted, EMS took to ER where pulseless. Ventricular tachycardia found. Intubated, CCU care, minimal brain activity, died on 4th day.


Changed on 10/14/2018

VAERS ID: 455522 Before After
VAERS Form:1
Age:67.0
Sex:Male
Location:Ohio
Vaccinated:2012-02-29
Onset:2012-03-07
Submitted:2012-05-14
Entered:2012-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR CA0300AA / 1 LA / IM

Administered by: Unknown      Purchased by: Private
Symptoms: Cyanosis, Death, Fall, Intensive care, Nervous system disorder, Pulse absent, Resuscitation, Ventricular tachycardia, Endotracheal intubation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2012-03-11
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lipitor, ECBASA, Diltiazem CD, HCTZ, albuterol
Current Illness:
Preexisting Conditions: Hypertension, IHSS, Bradycardia, Hypercholesterolemia, Allergic Rhinitis, Asthma
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt returned from arduous bike ride, took long time in bathroom, wife entered, pt started to speak, turned blue and fell to floor. CPR attempted, EMS took to ER where pulseless. Ventricular tachycardia found. Intubated, CCU care, minimal brain activity, died on 4th day.


Changed on 12/24/2020

VAERS ID: 455522 Before After
VAERS Form:1
Age:67.0
Sex:Male
Location:Ohio
Vaccinated:2012-02-29
Onset:2012-03-07
Submitted:2012-05-14
Entered:2012-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR CA0300AA / 1 LA / IM

Administered by: Unknown      Purchased by: Private
Symptoms: Cyanosis, Death, Fall, Intensive care, Nervous system disorder, Pulse absent, Resuscitation, Ventricular tachycardia, Endotracheal intubation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2012-03-11
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lipitor, ECBASA, Diltiazem CD, HCTZ, albuterol
Current Illness:
Preexisting Conditions: Hypertension, IHSS, Bradycardia, Hypercholesterolemia, Allergic Rhinitis, Asthma
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt returned from arduous bike ride, took long time in bathroom, wife entered, pt started to speak, turned blue and fell to floor. CPR attempted, EMS took to ER where pulseless. Ventricular tachycardia found. Intubated, CCU care, minimal brain activity, died on 4th day.


Changed on 12/30/2020

VAERS ID: 455522 Before After
VAERS Form:1
Age:67.0
Sex:Male
Location:Ohio
Vaccinated:2012-02-29
Onset:2012-03-07
Submitted:2012-05-14
Entered:2012-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR CA0300AA / 1 LA / IM

Administered by: Unknown      Purchased by: Private
Symptoms: Cyanosis, Death, Fall, Intensive care, Nervous system disorder, Pulse absent, Resuscitation, Ventricular tachycardia, Endotracheal intubation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2012-03-11
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lipitor, ECBASA, Diltiazem CD, HCTZ, albuterol
Current Illness:
Preexisting Conditions: Hypertension, IHSS, Bradycardia, Hypercholesterolemia, Allergic Rhinitis, Asthma
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt returned from arduous bike ride, took long time in bathroom, wife entered, pt started to speak, turned blue and fell to floor. CPR attempted, EMS took to ER where pulseless. Ventricular tachycardia found. Intubated, CCU care, minimal brain activity, died on 4th day.


Changed on 5/7/2021

VAERS ID: 455522 Before After
VAERS Form:1
Age:67.0
Sex:Male
Location:Ohio
Vaccinated:2012-02-29
Onset:2012-03-07
Submitted:2012-05-14
Entered:2012-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR CA0300AA / 1 LA / IM

Administered by: Unknown      Purchased by: Private
Symptoms: Cyanosis, Death, Fall, Intensive care, Nervous system disorder, Pulse absent, Resuscitation, Ventricular tachycardia, Endotracheal intubation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2012-03-11
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lipitor, ECBASA, Diltiazem CD, HCTZ, albuterol
Current Illness:
Preexisting Conditions: Hypertension, IHSS, Bradycardia, Hypercholesterolemia, Allergic Rhinitis, Asthma
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt returned from arduous bike ride, took long time in bathroom, wife entered, pt started to speak, turned blue and fell to floor. CPR attempted, EMS took to ER where pulseless. Ventricular tachycardia found. Intubated, CCU care, minimal brain activity, died on 4th day.


Changed on 5/21/2021

VAERS ID: 455522 Before After
VAERS Form:1
Age:67.0
Sex:Male
Location:Ohio
Vaccinated:2012-02-29
Onset:2012-03-07
Submitted:2012-05-14
Entered:2012-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (ADACEL) / SANOFI PASTEUR CA0300AA / 1 LA / IM

Administered by: Unknown      Purchased by: Private
Symptoms: Cyanosis, Death, Fall, Intensive care, Nervous system disorder, Pulse absent, Resuscitation, Ventricular tachycardia, Endotracheal intubation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2012-03-11
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lipitor, ECBASA, Diltiazem CD, HCTZ, albuterol
Current Illness:
Preexisting Conditions: Hypertension, IHSS, Bradycardia, Hypercholesterolemia, Allergic Rhinitis, Asthma
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt returned from arduous bike ride, took long time in bathroom, wife entered, pt started to speak, turned blue and fell to floor. CPR attempted, EMS took to ER where pulseless. Ventricular tachycardia found. Intubated, CCU care, minimal brain activity, died on 4th day.

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