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Spiked Helmet Sign in the Inferior Leads

To identify the key insights or developments described in this article
1 Credit CME

A patient in their 80s with a medical history of type 2 diabetes, hypertension, and poorly differentiated pulmonary adenocarcinoma was admitted to the critical care unit after experiencing a pulseless electrical activity cardiac arrest while receiving intravenous chemotherapy at an outpatient cancer center. They received 20 minutes of bystander chest compressions before the return of spontaneous circulation. On arrival to the intensive care unit, they were afebrile, their heart rate was 116 beats per minute, and their blood pressure was 85/55 mm Hg on mechanical ventilation. Laboratory examination results were unrevealing. Initial electrocardiogram (ECG) showed sinus tachycardia, heart rate of 109 beats per minute with normal intervals, and no acute ST-segment changes. Chest computed tomography angiography ruled out pulmonary embolism and aortic pathology. A transthoracic echocardiogram showed normal biventricular size and function without substantial valvular abnormalities. When intravenous norepinephrine was initiated, ST-segment and T-wave changes were noted on telemetry and confirmed on a 12-lead ECG, as shown in the Figure, A.

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A patient in their 80s with a medical history of type 2 diabetes, hypertension, and poorly differentiated pulmonary adenocarcinoma was admitted to the critical care unit after experiencing a pulseless electrical activity cardiac arrest while receiving intravenous chemotherapy at an outpatient cancer center. They received 20 minutes of bystander chest compressions before the return of spontaneous circulation. On arrival to the intensive care unit, they were afebrile, their heart rate was 116 beats per minute, and their blood pressure was 85/55 mm Hg on mechanical ventilation. Laboratory examination results were unrevealing. Initial electrocardiogram (ECG) showed sinus tachycardia, heart rate of 109 beats per minute with normal intervals, and no acute ST-segment changes. Chest computed tomography angiography ruled out pulmonary embolism and aortic pathology. A transthoracic echocardiogram showed normal biventricular size and function without substantial valvular abnormalities. When intravenous norepinephrine was initiated, ST-segment and T-wave changes were noted on telemetry and confirmed on a 12-lead ECG, as shown in the Figure, A.

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Article Information

Corresponding Author: Gan-Xin Yan, MD, PhD, Lankenau Medical Center, Main Line Health, 100 E Lancaster Ave, Wynnewood, PA 19096 (yang@mlhs.org).

Published Online: July 10, 2023. doi:10.1001/jamainternmed.2023.1728

Conflict of Interest Disclosures: Dr Yan is supported by the Sharpe-Strumia Research Foundation. No other disclosures were reported.

Meeting Presentation: This case was presented as a poster at AHA Scientific Sessions 2022 of the American Heart Association; November 5, 2022; Chicago, Illinois.

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(12):1245-1246. doi:10.4065/mcp.2011.0647PubMedGoogle ScholarCrossref
2.
Hamade  H , Jabri  A , Yusaf  A , Nasser  MF , Karim  S .  The spiked helmet sign: a concerning electrocardiographic finding.   JACC Case Rep. 2021;3(11):1370-1372. doi:10.1016/j.jaccas.2021.04.048PubMedGoogle ScholarCrossref
3.
Littmann  L .  Electrocardiographic artifact.   J Electrocardiol. 2021;64:23-29. doi:10.1016/j.jelectrocard.2020.11.006PubMedGoogle ScholarCrossref
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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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