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

Fatai Oluyadi¹, Pramod Theetha Kariyanna², Apoorva Jayarangaiah³, Jessica Celenza-Salvatore⁴ and Isabel M. McFarlane^4,

¹Department of Internal Medicine, Brookdale University Hospitals and Medical Center, 1 Brookdale Plaza, Brooklyn, New York, NY 11212, USA.

²Division of Cardiovascular Diseases, Department of Internal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA

³Department of Internal Medicine, NYC Health and Hospitals/Jacobi Medical Center, Bronx, New York, U.S.A-10461

⁴Department of Internal Medicine, State University of New York: Downstate Medical Center, Brooklyn, New York, United States-11203

Cite this paper:
Fatai Oluyadi, Pramod Theetha Kariyanna, Apoorva Jayarangaiah, Jessica Celenza-Salvatore and Isabel M. McFarlane. Helmet Sign on EKG: A Rare Indicator of Poor Prognosis in Critically Ill Patients. American Journal of Medical Case Reports. 2019; 7(10):260-263. doi: 10.12691/ajmcr-7-10-9

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.

Keywords:
helmet sign EKG critically ill STEMI poor prognosis

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