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The Ominous Spiked Helmet Sign on ECG

papercut lit review spiked helmet sign Mar 25, 2024

 The Case

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. Here are 2 questions to answer before you look at the answer below.

  1. Is this an acute Myocardial Infarction(AMI)?
  2. There is no cath lab in your hospital. Would you thrombolyse if she presented early?

This is an AMI mimic and not a true AMI. The elevation preceding the QRS is not consistent with acute coronary syndrome. The cause of this is thought to be due to a hyperadrenergic state. It is seen in:

  • acute abdominal pathology
  • intracranial haemorrhage
  • sepsis

It’s important to know that this is a pseudo-ST elevation, ie., not an acute myocardial infarction.

The Spiked Helmet Sign

Spiked Helmet Sign


Crinion D et al. Circulation. 2020


The QRS-ST segment resembles a Prussian military helmet and is thus known as the spiked helmet sign.


The CASE cont…..

The patient’s ecg changes resolved as below and there was no significant rise in cardiac enzymes.



Crinion D et al. Circulation. 2020;141:2106–2109



  1. Crinion D et al. An Ominous ECG Sign in Critical Care. Circulation. 2020;141:2106–2109

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