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This is VAERS ID 465397

Case Details

VAERS ID: 465397 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: Missouri  
Vaccinated:2012-08-15
Onset:2012-08-16
   Days after vaccination:1
Submitted: 2012-09-04
   Days after onset:19
Entered: 2012-09-18
   Days after submission:14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B33CE / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0221AE / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 918242 / 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB288A / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Cardio-respiratory arrest, Death, Respiratory arrest, Resuscitation
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), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2012-08-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Oral NaCl
Current Illness: Nasal congestion
Preexisting Conditions: Pre-term birth; Hyponatremia
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient found at home not breathing, CPR started. EMS continued CPR & brought patient to our ED. Patient still in full cardiopulmonary arrest. Patient never recovered heart rate.


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