An Ominous ECG Sign

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This is a fantastic case to learn from for a recent Circulation article(1) titled ‘An Ominous ECG Sign in Critical Care’.


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

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
Posted in , ,

Dr Peter Kas

Emergency Physician, Educator. Key Interests: Resuscitation, Airway, Emergency Cardiology, Clinical Examination. Creator


  1. Raja on 26/06/2020 at 11:19 am

    If there is a Cath Lab within 40mins, should this case be referred to Cardiology for an angiogram? I work in an UCC which has access to Cardiology services at tertiary centre within 40mins.

  2. Samarrae on 26/06/2020 at 7:28 pm

    To me , this ECG is a VT : wide complex , no P waves seen ,with MI as an underlying cause…
    The only factors I may consider – against MI – is age 35, and sex being a female- so I was thinking of metabolic causes like hyperkalemia esp. in the setting of acidosis which is well known to cause VT mimic.
    if the ecg will not normalize quickly after calciun and sod.bicarb , I will send the patient to cath lab…
    very challenging case …Thanksssssssssssss

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