A 35 yo woman with Septic Shock

A 35 year old woman, who is a known intravenous drug user, is admitted with septic shock secondary to bacterial endocarditis. She is acidotic and hypotensive. Her ECG is shown. 

Crinion D et al. Circulation. 2020(1)

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Answer the following 3 questions:

Can you recognise this sign?

The Spiked Helmet Sign

Is this an acute myocardial infarction?

No This is a STEMI mimic. It does however occur in critically ill patients.

If your hospital had no cath lab, would you thrombolyse?

Beware with the spiked helmet sign. You have to look beyond the heart for the cause. Always, when you see this sign get a cardiology opinion, certainly prior to thrombolysis and look for the ST elevation beginning before the QRS, which gives this diagnosis. See the details below.

This certainly looks like ST elevation, but is actually a mimic. If you look at the complexes, the upward shift starts before the onset of the QRS complex. There is a dome-and-spike pattern, similar to a Prussian military helmet. This has been called the 'Spiked Helmet Sign'.
​It is a STEMI mimic and usually found in critically ill patients with no cardiac pathology. In one case series by Littmann(2), 8 patients with this sign were presented. None had a cardiac illness and 6 of the 8 patients died. In some cases, the sign was only after intubation and it is postulated that the mechanism for this ST elevation is related to repetitive epidermal stretch due to an acute elevation in intra-thoracic or intra-abdominal pressure. Below is another example.

So remember the helmet sign. It is usually present in critically ill patients. Think of sepsis, or abdominal conditions ie., think beyond cardiac.

References

1. Crinion D et al. An Ominous ECG Sign in Critical Care. Circulation. 2020;141:2106–2109
2. Littmann L et al. Mayo Clin Proc. Dec 2011;86(12):1243-48