An Ominous ECG Finding: Spiked Helmet Sign

You respond to a patient complaining of intense abdominal pain and dyspnea. Due to the complaint you run a 12-lead and note the rhythm note the ECG below.

You note ST elevation in the inferior leads with upwardly shifted QRS complexes nearly resting on top of them (Leads II and aVF are the best examples). This ECG manifestation is referred to as spiked helmet sign… It’s about as ominous as Michael Myers standing outside of your bedroom window.

If you’re fluent in mid to late 1800’s European history, you may have heard of King Friedrich Wilhelm IV of Prussia. This sign is named after the spiked helmets his military wore due to the similar appearance.

So, before you activate the cath lab, please finish reading….

What exactly is spiked helmet sign? This sign is mostly seen in critically ill patients with GI related issues such as gastric dilatation, intestinal obstruction, cholecystitis, hepatitis, and pancreatitis (Spiked Helmet Sign: An Electrocardiographic Indication of Impending Doom). This occurs mostly in the inferior leads due to their proximity to the diaphragm and abdominal cavity. It’s been suggested that changes in the hearts position by diaphragmatic elevation are the underlying causes of the ST-elevations.

What to look for on the 12 lead ECG:

  1. Upward shifting QRS complexes from isoelectric line
  2. ST segment elevation
  3. Spike on top of a dome appearance

This sign has a 75% mortality rate. This 12-lead ECG manifestation was noted in a study that included 8 patients. Six out of the eight patients died between 1-10 days later. Two were discharged but were extremely debilitated. One was sent to a rehabilitation center and the other to a skilled nursing facility. So if you ever see this, you can view it as an army marching forward with full intentions of killing your patient.

Final thoughts…

We know that the differential for ST-segment elevation is huge. While always keeping STEMI at the forefront of our thought process, it’s essential to perform thorough physical exams and history gathering in an effort to capture the full clinical picture. It’s of combination of the ECG, history, and physical exam findings that lead us down the road to appropriate decision making for our patients.

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This site is meant to be used for educational use only. We strive to push evidence based medicine with no bias to help you obtain all the important information. You should always follow your protocols that have been set in place.

Scopeducation Team (Matt)


Cisewski, David. “Spiked Helmet Sign: An Electrocardiographic Indication of Impending Doom.” – Emergency Medicine Education, 2 Apr. 2019,

Littmann, Laszlo, and Michael H Monroe. “The ‘Spiked Helmet’ Sign: a New Electrocardiographic Marker of Critical Illness and High Risk of Death.” Mayo Clinic Proceedings, Mayo Foundation for Medical Education and Research, Dec. 2011,

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