VAERS ID: 1225942

AGE: 16| SEX: F|STATE: WI

Description

Patient was a 16yr female who received Pfizer vaccine 3/19/21 at vaccine clinic and presented with ongoing CPR to the ED 3/28/21 after cardiac arrest at home. Patient placed on ECMO and imaging revealed bilateral large pulmonary embolism as likely etiology of arrest. Risk factors included oral contraceptive use. Labs have since confirmed absence of Factor V leiden or prothrombin gene mutation. Patient declared dead by neurologic criteria 3/30/21.

Symptoms

Cardiac arrest, Death, Laboratory test, Lung assist device therapy, Oral contraception, Pulmonary embolism, Resuscitation

Vaccines

VAX DATE: 03-19-2021| ONSET DATE: 03-28-2021| DAYS TO ONSET: 9
NameDose #TypeManufacturerLotRouteSite
COVID19 (COVID19 (PFIZER-BIONTECH)) 1 COVID19 PFIZER\BIONTECH Unknown Unknown Unknown

RECVDATE:04-18-2021
RPT_DATE:
CAGE_YR:16
CAGE_MO:
DIED:Y
DATEDIED:03-30-2021
L_THREAT:U
ER_VISIT:U
HOSPITAL:U
HOSPDAYS:
X_STAY:U
DISABLE:U
RECOVD:N
LAB_DATA:
V_ADMINBY:
OTHER_MEDS:Reported to be on Drospirenone-Ethinyl Estradiol 3-0.02 MG per tab
CUR_ILL:
HISTORY:
PRIOR_VAX:
SPLTTYPE:
FORM_VERS:2
TODAYS_DATE:04-18-2021
BIRTH_DEFECT:U
OFC_VISIT:U
ER_ED_VISIT:U
ALLERGIES:
V_FUNDBY:

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