Helmet Sign on EKG: A Rare Indicator of Poor Prognosis in Critically Ill Patients

Abstract

Background: The 'Spiked Helmet' is an electrocardiogram (EKG) finding occasionally seen in critically ill patients characterized by ST segment elevation usually represented as a 'spike and dome' pattern with elevation in the EKG baseline prior to the R wave and adjoining ST segment elevation resembling the German military helmet of the Prussian Empire. In the few cases reported in literature, this finding has been associated with very poor clinical outcomes, including in-hospital death. Although ST elevation is not uncommon in critically ill patients, these findings of a 'Spiked Helmet' sign are often transient and typically not associated with acute coronary syndrome. Case presentation: A 56-year-old male was found unresponsive by his relatives at home. It was an unknown the time that he had been unconscious. When the emergency medical services arrived, patient was found to be in pulseless electrical activity (PEA). Patient achieved return to spontaneous circulation (ROSC) 15 minutes after initiation of advanced cardiac life support protocol. An electrocardiogram done immediately post ROSC showed ST elevations in inferior and lateral leads. Patient was brought to the hospital as a ST elevated myocardial infarction (STEMI) arrest. The EKG revealed the Helmet sign in leads aVL and II, also ST segment elevation was noted in V1, V2, V3 and ST segment depression was noted in V5 and V6. Troponin was negative at the time of initial evaluation but trended up gradually during the hospitalization. A computed tomography (CT) pulmonary angiogram was negative for pulmonary embolism. A head CT showed diffuse anoxic brain injury. Patient was started on the hypothermia protocol. Upon family request patient was terminally extubated two days into hospital stay and expired shortly after. Conclusion: Although we are yet to fully understand the significance of the 'Spiked Helmet' Sign, this case report and literature review offers a comprehensive overview of the reported cases and draws important links and clues from them.

The “Spiked Helmet” Sign Associated with ST-Elevation Myocardial Infarction: A Case Report

“…1 We found only one report of a patient with the "spiked helmet" sign interpreted as a myocardial infarction, but the documentation is poor and coronary angiography was not performed. 5 In our case we can clearly associate the "spiked helmet" sign to an acute major coronary artery occlusion resulting in myocardial infarction. A nonspecific intraventricular block in the inferior leads and a slightly long QTc could have played a role leading to this particular ECG configuration.…”

The Spiked Helmet Sign

“…The spiked helmet sign is a recently described ECG finding and is often associated with critical illness and a high risk of mortality. It has also been associated with increased intrathoracic or intra-abdominal pressures, sepsis, respiratory distress, subarachnoid hemorrhage, and anoxic brain injury ( 2 ). It is not a sign of cardiac pathology and is usually self-limited without any lasting ECG changes ( 1 , 2 ).…”

“…It has also been associated with increased intrathoracic or intra-abdominal pressures, sepsis, respiratory distress, subarachnoid hemorrhage, and anoxic brain injury ( 2 ). It is not a sign of cardiac pathology and is usually self-limited without any lasting ECG changes ( 1 , 2 ). Although the exact mechanism behind it is not fully understood, diaphragmatic breathing, synchronization of the cardiac pulse with pulsatile diaphragmatic contractions, and repetitive epidermal stretching have all been suggested as potential factors playing a role in the development of the sign ( 1 , 2 ).…”

“…It is not a sign of cardiac pathology and is usually self-limited without any lasting ECG changes ( 1 , 2 ). Although the exact mechanism behind it is not fully understood, diaphragmatic breathing, synchronization of the cardiac pulse with pulsatile diaphragmatic contractions, and repetitive epidermal stretching have all been suggested as potential factors playing a role in the development of the sign ( 1 , 2 ). In this case, the patient was in a critical state, had a history of subarachnoid hemorrhage, and was being treated for severe lung infections, which are all features associated with the spiked helmet sign.…”

„STEMI mimics“

“…Das „spiked helmet sign“ (Pickelhaubenzeichen) ist eine seltene, erstmals in 2011 beschriebene EKG-Veränderung [ 21 ], welche bei nichtkardialen schweren Erkrankungen wie z. B. Sepsis, abdominellen Erkrankungen oder Hirnblutungen auftreten kann [ 23 ]. Wenn dieses Zeichen detektierbar ist, ist mit einer deutlich erhöhten Mortalität zu rechnen.…”