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This is VAERS ID 463211

Case Details

VAERS ID: 463211 (history)  
Form: Version 1.0  
Age: 0.39  
Sex: Female  
Location: Alabama  
Vaccinated:2012-08-06
Onset:2012-08-15
   Days after vaccination:9
Submitted: 2012-08-17
   Days after onset:2
Entered: 2012-08-27
   Days after submission:10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3970AA / 2 UN / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH F30921 / 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1540AA / 2 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Cardiac arrest, Intensive care, Respiratory failure
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2012-08-16
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Runny nose; no fever
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 8/15/12 05:51 - presented to ER in full arrest - brought by EMS. Admitted to the PICU with diagnosis of cardiac arrest, respiratory failure.


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