An Ominous ECG Sign in Critical Care

Circulation

CASES AND TRACES

  

ECG CHALLENGE

A 35-year-old woman was admitted to the critical care unit for treatment of septic shock. She had developed an abscess in her right hand and group A strep- tococcal bacteremia as a result of intravenous drug abuse. A transesophageal echocardiogram detected a vegetation on the tricuspid valve, with mild to mod- erate regurgitation. Septic emboli to the lungs were evident on computed to- mography scan. She was hypotensive (85/55 mm Hg), acidotic (pH 7.18), requir- ing inotropic support and invasive ventilation. A 12-lead ECG was performed because ST-segment elevation was observed on the cardiac monitor. What is the ECG sign in Figure 1?

Please turn the page to read the diagnosis.

Derek Crinion , MD Hoshiar Abdollah, MD

Adrian Baranchuk

, MD

 

Figure 1. The 12-lead ECG recorded in the critical care unit.

2106 June 23/30, 2020

Circulation. 2020;141:2106–2109. DOI: 10.1161/CIRCULATIONAHA.120.047427

© 2020 American Heart Association, Inc.

https://www.ahajournals.org/journal/circ

Downloaded from http://ahajournals.org by on July 4, 2020

Crinion et al ECG Challenge

  

Figure 2. Spiked-helmet sign named for its resemblance to the Prussian military helmet, the Pickelhaube.

RESPONSE TO ECG CHALLENGE

The QRS-ST segment in Figure 1 is characteristic of the spiked-helmet sign (SHS). The elevation of the isoelec- tric line precedes the QRS, followed by a sharp R wave and then convex ST-segment elevation. First described by Littmann et al1 in 2011, this characteristic ECG pat- tern was named for its resemblance to the Prussian military helmet, the Pickelhaube (Figure 2). The 12-lead distribution was initially described only in the inferior leads,1 but the pattern can be widespread as is evident in this case.

The mechanism of this ECG sign is not fully under- stood. SHS was rst detected in cases of acute abdo- men and thoracic pathology.1,2 As a result, it was pos- tulated that the ECG pattern was an artifact from the voltage generated by mechanical epidermal stretch caused by a rapid increase in intra-abdominal or tho- racic pressure.1,2 However, subsequent reports demon- strated SHS in cases of intracranial hemorrhage, sepsis, and metabolic derangement.2 A unifying explanation emerged in that SHS was caused by adrenergically mediated prolongation of repolarization.2 Such condi- tions were established causes of acquired long QT.2 SHS may be an extreme manifestation.2 The characteristic pattern may be formed by the preceding beat’s late and giant T-U waves superimposed on the QRS.2 The

hypothesis of a hyperadrenergic state was further sup- ported by the detection of SHS after stellate ganglion ablation.2 Furthermore, macroscopic T-wave alternans and torsade de pointes are associated features of both long QT and SHS.2 Given the shared pathophysiology of adrenergic excess, concomitant takotsubo cardiomy- opathy has also been described.2

SHS mimics acute myocardial infarction. However, the upward shift preceding the QRS that can appear to align with the ST-segment elevation is not consis- tent with acute coronary syndrome.1,2 Aforementioned causes of SHS should rst be considered, in particular, intracranial hemorrhage, before antithrombotic drugs are administered as part of acute coronary syndrome protocol. Our patient’s ECG progressively resolved within 24 hours as she responded to antibiotics and supportive measures (Figure 3). Note the absence of Q waves or T-wave inversion that is typical of ECG evo- lution after ischemic ST-segment elevation.1,2 Cardiac enzymes were not signi cantly elevated in this case. SHS is the most recent addition to the differential di- agnoses of pseudo–ST-segment elevation myocardial infarction pattern. Better recognized causes include pericarditis, bundle-branch block, hypertrophy, hy- perkalemia, hypercalcemia, large pulmonary embo- lism, postcardioversion, digoxin toxicity, early repo- larization, and Brugada syndrome.3 These were also

Circulation. 2020;141:2106–2109. DOI: 10.1161/CIRCULATIONAHA.120.047427

June 23/30, 2020 2107

CASES AND TRACES

Downloaded from http://ahajournals.org by on July 4, 2020

Crinion et al ECG Challenge

  

Figure 3. Progressive resolution of patient’s ECG within 24 hours.
A
, Spiked-helmet sign becomes less pronounced with clinical recovery. B, Spiked-helmet sign has completely resolved. The QTc interval is within normal range. Also note the absence of Q waves or T-wave inversion that would be indicative of ECG evolution after ischemic ST-segment elevation.

considered in our case but were inconsistent with the available clinical, ECG, laboratory, and imaging nd- ings at the time.

Given its relatively recent description, SHS remains limited to case reports and small series.1,2 Its true prev- alence in the critical care setting is unknown. SHS is

usually recognized retrospectively and is associated with a high in-hospital mortality rate.1,2 In the index case se- ries, 6 of the 8 patients died 1 to 10 days after the rst ECG recording of SHS (mean, 5.5 days).1,2 Development of this ominous ECG sign in critically ill patients should prompt urgent reassessment. Greater awareness of SHS

2108 June 23/30, 2020

Circulation. 2020;141:2106–2109. DOI: 10.1161/CIRCULATIONAHA.120.047427

CASES AND TRACES

Downloaded from http://ahajournals.org by on July 4, 2020

Crinion et al

ECG Challenge

  

and its pattern recognition will guide physicians to rst consider acute nonischemic pathogenesis.

ARTICLE INFORMATION Correspondence

Adrian Baranchuk, MD, FACC, FRCPC, FCCS, Professor of Medicine, Clinical Electrophysiology and Pacing, Kingston Health Sciences Centre, Queen’s Univer- sity, Kingston, K7L 2V7, ONT, Canada. Email Adrian.Baranchuk@kingstonhsc.ca

Af liation

Kingston Health Sciences Centre, Queen’s University, Ontario, Canada.

Disclosures

None.

REFERENCES

1. Littmann L, Monroe MH. The “spiked helmet” sign: a new electrocardio- graphic marker of critical illness and high risk of death. Mayo Clin Proc. 2011;86:1245–1246. doi: 10.4065/mcp.2011.0647

2. Simon A, Járai Z. Is the spiked helmet sign the manifestation of long QT syndrome? J Electrocardiol. 2019;55:16–19. doi: 10.1016/j.jelectrocard. 2019.04.011

3. WangK,AsingerRW,MarriottHJ.ST-segmentelevationinconditionsoth- er than acute myocardial infarction. N Engl J Med. 2003;349:2128–2135. doi: 10.1056/NEJMra022580

 

Circulation. 2020;141:2106–2109. DOI: 10.1161/CIRCULATIONAHA.120.047427

June 23/30, 2020 2109

CASES AND TRACES

Downloaded from http://ahajournals.org by on July 4, 2020

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: