Age: 14.0
Sex: F
Vaccine: COVID19
Symptoms: Poor peripheral circulation, Presyncope, Tremor
Clinical narrative: Patient is a 14 year old female brought in by mother for COVID Vaccination, dose # 1 of the Pfizer BioNTech vaccine under emergency use authorization.   Screening Prior to Vaccination: Is there a current illness or fever? No Has the patient ever had a severe (anaphylactic) reaction to any trigger? No Has the patient had a severe (anaphylactic) reaction to any vaccine or vaccine component? No Has the patient ever had myocarditis? no Does the patient have a bleeding disorder or use a blood thinner? no Is the patient immunocompromised? no For Females: Is the patient pregnant, planning to become pregnant or breast feeding? No Has the patient ever fainted from a vaccination? no Has the patient received a COVID vaccination before? No  Patient Assessment Patient's temperature is 97.5 degrees, taken by contactless forehead method. Consent Verbal informed consent was obtained by parent. . Monitoring and Discharge Patient was monitored for 15 minutes following vaccination. There were any reactions. The patient was noted to have nausea and pallor 10 minutes after vaccine administration.. The patient required brief rest in supine position and epinephrine. Additional details about the reaction: see below.  Patient received her first dose of the covid vaccine around 2:15pm. Approximately 5-10 minutes later, patient's mother alerted the nurse that patient was experiencing nausea. Nurse followed mother to the bathroom where patient was kneeling on the floor in front of the toilet. Patient was extremely pale, shaky, and complaining of nausea. Nurse brought patient water, a chair to sit in, and took her pulse and oxygen level with pulse oximeter machine. Pulse ox was in 97-99% range, and heart rate was in the upper 90s. Due to the patient's ill appearance, nurse went to get a BP cuff and alerted physician of the situation as she was getting one. Physician arrived in the bathroom. Nurse took BP- 110/72 at this time. Physician did a physical exam of patient and instructed nurse to have patient lie down with feet elevated and monitor her. Nurse took patient back to the exam room, laid her in supine position, elevated feet with a pillow, and left the room for approximately another 4-5 minutes.   Mother again alerted nurse that pulse oximeter machine was beeping, and nurse returned to room. Patient was still complaining of nausea and appeared very pale. Patients pulse was in the 50s and low 60s, and her pulse ox was holding stead at 97-99% range. Nurse took a manual heart rate with stethoscope to verify accuracy of pulse oximeter machine- 60bpm. Nurse took BP again- 92/62. Nurse alerted physician.  Physician came to exam room, examined patient. Patient was still complaining of severe nausea. Patient was still extremely pale. Physician BP- 98/58. HR still in 50s and 60s.  Decision was made by physician to give 0.3mg of epinephrine to patient and call 911. Nurse alerted front office staff to call 911. Nurse drew up 0.3mg of epi, dose was verified by physician and second nurse. Nurse administered 0.3mg of epi to patient at 2:49pm.  Ambulance arrived approximately 5 minutes later.  Ambulance team took over monitoring patient vitals. Ambulance team advised mom that if she went to the hospital she would just have to wait and then be sent home. Mom requested to speak with physician, who advised mom that patient needed to go to the hospital for monitoring. After physician left the room, ambulance team member told mom that she had worked at the hospital, and she knew that the care patient would receive at the hospital would not be different than the care elsewhere. Nurse communicated with mom that physician recommended patient be taken via ambulance to be seen at the hospital as she had a serious allergic reaction to the COVID vaccine, and she needs to be under observation.  Discussed option to be monitored at hospitals' urgent care versus ER to save on cost.  Mom was concerned about the cost of an expensive ambulance ride, and she ultimately opted to drive to an alternate hospital (across the street from the office) against the advice of the physician and nurse.  Nurse advised mom that she needed to drive immediately to the alternate hospital. Instructed mom that if patient deteriorated in the car to call 911 immediately. Mom agreed.  At the time of patient leaving, she was still complaining of nausea. She was no complaining of headache as well. Color had improved. Blood pressure was up, 110s over 70s. Heart rate was still in 60s.   Immediately after patient left nurse notified physician of mom's decision to drive to alternate hospital. Note: Epinephrine Lot #: 27670 Epinephrine Expiration Date: 09/2022 Administered in left vastus lateralis muscle  - Nurse  --- Agree with above.  Initially, felt reaction was likely vasovagal response to vaccine (although had not occurred for her with prior vaccines/bloodwork).  No wheezing, difficulty breathing, cough, or rash.  Timing seemed prolonged for a vasovagal event and was worsening over 30 minutes of monitoring.  Due decreasing BP, decreasing HR (although lower than her norm based on prior vitals- not tachycardic), poor perfusion, pallor, headache, and persistent nausea- even after laying down with feet elevated, drinking water, resting, and monitoring, decided to give epi for possible allergic reaction and send to the ER for monitoring.  Per mom, patient was monitored at a hospital.  ER doctor felt most likely a vasovagal response rather than anaphylactic reaction.  She is doing better.  Physician  Assessment Need for vaccination   Plan Orders COVID-19  8/12/2021 Admin COVID dose 1  8/12/2021 Instructions Pfizer BioNTech fact sheet given and reviewed. Side effects listed on the fact sheet include allergic reactions (severe and non severe), myocarditis, pericarditis, injection site pain and/or swelling, fatigue, fever, chills, muscle pain, headache. Signs of myocarditis for which to call include chest pain, palpitations or fluttering or pounding heart, shortness of breath. Call or seek emergency care if these signs occur.