The Spiked Helmet Sign: When ST-Segment Elevations Do Not Need the Cath Lab

Critically ill patients often develop electrocardiographic (ECG) changes that are difficult to interpret, making it challenging to distinguish primary cardiac pathology from ECG manifestations of systemic illness. The spiked helmet sign (SHS) is a recognized pattern in this context, and real-time identification may be challenging.

A 45-year-old man with HIV/AIDS admitted for pneumonia developed septic shock, stress-induced cardiomyopathy, and multiorgan failure. Telemetry monitoring revealed a wide complex rhythm, initially interpreted as ventricular tachycardia, and synchronized cardioversion was performed without effect. A 12-lead electrocardiogram demonstrated sinus rhythm with ST-segment elevations occurring before the QRS complex, consistent with SHS rather than a ventricular rhythm. Coronary angiogram was deferred, given clinical features not supporting acute coronary syndrome. The patient developed worsening multiorgan failure and died shortly thereafter.

The case illustrates the importance of recognition of the SHS in critically ill patients as a marker of ominous prognosis in systemic illness, rather than primary cardiac pathology.

Recognition of SHS is important to avoid unnecessary cardiac intervention and redirect management toward extracardiac causes of deterioration.