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This is VAERS ID 469713

Case Details

VAERS ID: 469713 (history)  
Form: Version 1.0  
Age: 77.0  
Sex: Male  
Location: Washington  
Vaccinated:2012-09-18
Onset:2012-09-18
   Days after vaccination:0
Submitted: 2012-10-11
   Days after onset:23
Entered: 2012-10-15
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / NOVARTIS VACCINES AND DIAGNOSTICS 12251P / 2 RA / UN

Administered by: Unknown       Purchased by: Unknown
Symptoms: Cardiac arrest, Respiratory depression, Tachycardia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Respiratory failure (narrow), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2012-09-18
   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:
Current Illness: Recently discharged for CHF exacerbation
Preexisting Conditions: CHF; Peripheral vascular disease; Hyperlipidemia; Atrial fibrillation; Foot amputation
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resp. Depression, Tachycardia and Cardiac Arrest. Epinephrine 1 MG Other, Dopamine 10 MCG Other.


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