International Journal of Cardiology 173 (2014) e51–e52
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Real time recognition of the electrocardiographic “spiked helmet” sign in a critically ill patient with pneumothorax Laszlo Littmann ⁎,1, Patrick Proctor Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC, USA
a r t i c l e
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Article history: Received 31 January 2014 Accepted 14 March 2014 Available online 21 March 2014 Keywords: Critical illness Electrocardiogram Pneumothorax
A few years ago we described a new electrocardiographic (ECG) finding characterized by a dome-and-spike patterned apparent STsegment elevation where the upward shift of the baseline started before and ended after the QRS complex [1]. The ECG morphology resembled the shape of a German military spiked helmet. The presence of this “spiked helmet” sign was found to be associated with critical illness and very high risk of in-hospital death. In all 8 presented cases the pseudo-ST elevation was seen in the inferior leads and in many cases, the presumed cause was an acute abdominal event [1]. Subsequent to our publication Chaudhry et al. described a critically ill patient with ileus who developed transient tombstone ST-segment elevation in the inferior leads [2]. Emergent cardiac catheterization revealed normal coronary arteries, and the patient ruled out for myocardial infarction. In hindsight, the ECG of that patient too was consistent with the spiked helmet sign [3]. Tomcsányi et al. reported on a patient who died of a traumatic thoracic aortic dissection. A re-review of the patient's premortem ECG was found to be consistent with the spiked helmet sign in the chest leads [4]. Importantly, in each of the cases reported so far the spiked helmet sign was recognized in retrospection, in the majority of cases following the patient's death. The purpose of this report is to present the first case where the spiked helmet sign was discovered real time leading to a successful search for the underlying cause. A 73-year-old man had prolonged hospitalization for recurrent aspiration pneumonia, adult respiratory distress syndrome, respiratory and hemodynamic failure requiring mechanical ventilation and the use of
⁎ Corresponding author at: Department of Internal Medicine, Carolinas Medical Center, P. O. Box 32861, Charlotte, NC 28232, USA. Tel.: +1 704 355 3165. E-mail address: [email protected] (L. Littmann). 1 This author takes full responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
http://dx.doi.org/10.1016/j.ijcard.2014.03.105 0167-5273/© 2014 Elsevier Ireland. Ltd. All rights reserved
vasopressors. On the last hospital day the telemetry monitor appeared to show ST-segment elevation. On the follow-up 12-lead ECG the spiked helmet sign was recognized in the mid-precordial leads (Fig. 1). This finding raised the possibility of an acute thoracic event. Chest X-ray revealed a new moderate sized right-sided pneumothorax with mild shift of the mediastinum to the left (Fig. 2). Family members expressed the patient's desire for natural death and requested that a chest tube not be placed. The patient expired 21 h after recognition of the spiked helmet sign. The exact mechanism of the spiked helmet pattern and its association with critical illness are uncertain. Our original observations [1], the observations by Tomcsányi et al. [4] and the current report all suggest that the pseudo-ST segment elevation is probably due to repetitive epidermal stretch that occurs in concert with the cardiac cycle. The underlying cause in most cases appears to be an acute rise in intrathoracic or intra-abdominal pressure. Acute abdominal events may give rise to the spiked helmet pattern in the inferior ECG leads, whereas acute thoracic events may cause the spiked helmet sign in the chest leads. The presence of the spiked helmet sign is associated with critical illness and a very high risk of death. Recognition of this curious ECG pattern therefore should prompt an immediate search for the underlying cause, usually an acute non-cardiac condition. Acknowledgment The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. References [1] Littmann L, Monroe MH. The “spiked helmet” sign: a new electrocardiographic marker of critical illness and high risk of death. Mayo Clin Proc 2011;86:1245–6. [2] Chaudhry M, Omar Z, Latif F. Tombstone ST elevations: … not necessarily a harbinger of doom! Am J Med 2013;126:e5–6. [3] Littmann L, Monroe MH. Tombstone ST elevation without myocardial infarction: a variant of the “spiked helmet” sign? Am J Med 2013;126:e9-10. [4] Tomcsányi J, Frész T, Bózsik B. ST elevation anterior “spiked helmet” sign. Mayo Clin Proc 2012;87:309.
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L. Littmann, P. Proctor / International Journal of Cardiology 173 (2014) e51–e52
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Fig. 1. Electrocardiogram of a critically ill patient who was noted to have possible ST-segment elevation in telemetry. The mid-precordial leads (left) demonstrated repetitive upward baseline shift that started before and ended after the QRS complexes. The enlargement on the right illustrates the similarity of this dome-and-spike pattern to the shape of a German military spiked helmet.
Fig. 2. Chest X-ray revealed a moderate-sized right-sided pneumothorax (arrows) with possible mild shift of the mediastinum to the left.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Real time recognition of the electrocardiographic “spiked helmet” sign in a critically ill patient with pneumothorax Laszlo Littmann ⁎,1, Patrick Proctor Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC, USA
a r t i c l e
i n f o
Article history: Received 31 January 2014 Accepted 14 March 2014 Available online 21 March 2014 Keywords: Critical illness Electrocardiogram Pneumothorax
A few years ago we described a new electrocardiographic (ECG) finding characterized by a dome-and-spike patterned apparent STsegment elevation where the upward shift of the baseline started before and ended after the QRS complex [1]. The ECG morphology resembled the shape of a German military spiked helmet. The presence of this “spiked helmet” sign was found to be associated with critical illness and very high risk of in-hospital death. In all 8 presented cases the pseudo-ST elevation was seen in the inferior leads and in many cases, the presumed cause was an acute abdominal event [1]. Subsequent to our publication Chaudhry et al. described a critically ill patient with ileus who developed transient tombstone ST-segment elevation in the inferior leads [2]. Emergent cardiac catheterization revealed normal coronary arteries, and the patient ruled out for myocardial infarction. In hindsight, the ECG of that patient too was consistent with the spiked helmet sign [3]. Tomcsányi et al. reported on a patient who died of a traumatic thoracic aortic dissection. A re-review of the patient's premortem ECG was found to be consistent with the spiked helmet sign in the chest leads [4]. Importantly, in each of the cases reported so far the spiked helmet sign was recognized in retrospection, in the majority of cases following the patient's death. The purpose of this report is to present the first case where the spiked helmet sign was discovered real time leading to a successful search for the underlying cause. A 73-year-old man had prolonged hospitalization for recurrent aspiration pneumonia, adult respiratory distress syndrome, respiratory and hemodynamic failure requiring mechanical ventilation and the use of
⁎ Corresponding author at: Department of Internal Medicine, Carolinas Medical Center, P. O. Box 32861, Charlotte, NC 28232, USA. Tel.: +1 704 355 3165. E-mail address: [email protected] (L. Littmann). 1 This author takes full responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
http://dx.doi.org/10.1016/j.ijcard.2014.03.105 0167-5273/© 2014 Elsevier Ireland. Ltd. All rights reserved
vasopressors. On the last hospital day the telemetry monitor appeared to show ST-segment elevation. On the follow-up 12-lead ECG the spiked helmet sign was recognized in the mid-precordial leads (Fig. 1). This finding raised the possibility of an acute thoracic event. Chest X-ray revealed a new moderate sized right-sided pneumothorax with mild shift of the mediastinum to the left (Fig. 2). Family members expressed the patient's desire for natural death and requested that a chest tube not be placed. The patient expired 21 h after recognition of the spiked helmet sign. The exact mechanism of the spiked helmet pattern and its association with critical illness are uncertain. Our original observations [1], the observations by Tomcsányi et al. [4] and the current report all suggest that the pseudo-ST segment elevation is probably due to repetitive epidermal stretch that occurs in concert with the cardiac cycle. The underlying cause in most cases appears to be an acute rise in intrathoracic or intra-abdominal pressure. Acute abdominal events may give rise to the spiked helmet pattern in the inferior ECG leads, whereas acute thoracic events may cause the spiked helmet sign in the chest leads. The presence of the spiked helmet sign is associated with critical illness and a very high risk of death. Recognition of this curious ECG pattern therefore should prompt an immediate search for the underlying cause, usually an acute non-cardiac condition. Acknowledgment The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. References [1] Littmann L, Monroe MH. The “spiked helmet” sign: a new electrocardiographic marker of critical illness and high risk of death. Mayo Clin Proc 2011;86:1245–6. [2] Chaudhry M, Omar Z, Latif F. Tombstone ST elevations: … not necessarily a harbinger of doom! Am J Med 2013;126:e5–6. [3] Littmann L, Monroe MH. Tombstone ST elevation without myocardial infarction: a variant of the “spiked helmet” sign? Am J Med 2013;126:e9-10. [4] Tomcsányi J, Frész T, Bózsik B. ST elevation anterior “spiked helmet” sign. Mayo Clin Proc 2012;87:309.
e52
L. Littmann, P. Proctor / International Journal of Cardiology 173 (2014) e51–e52
V3
V4
V5
Fig. 1. Electrocardiogram of a critically ill patient who was noted to have possible ST-segment elevation in telemetry. The mid-precordial leads (left) demonstrated repetitive upward baseline shift that started before and ended after the QRS complexes. The enlargement on the right illustrates the similarity of this dome-and-spike pattern to the shape of a German military spiked helmet.
Fig. 2. Chest X-ray revealed a moderate-sized right-sided pneumothorax (arrows) with possible mild shift of the mediastinum to the left.
