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Aims ST segment elevation is an electrocardiogram (ECG) finding first of all suggestive of acute coronary syndrome (ACS). However, there are other causes of ST segment elevation that seem to not have any relationship with coronary artery disease (CAD). One of these is the so-called ‘Spiked Helmet Sign’ (SHS), an ECG pattern characterized by upslope of ST segment before R wave onset that is reported to be found in critical illness and is associated with negative outcomes. Methods and results A 14-years-old boy came comatose (Glasgow Coma Scale = 4) to the Emergency Room after being run over by a car. He was immediately intubated and mechanically ventilated. Baseline ECG was reported to be normal, showing an incomplete right bundle branch block and a slightly prolonged QTc interval. CT-scan showed subarachnoid haemorrhage and multiple skull fractures requiring decompressive craniectomy. During hospitalization the patient developed marked hypotension complicated by rise of inflammation indexes and 12 lead ECG revealed new-onset of diffuse ST-segment elevation with spike-and-dome appearance mainly in lateral precordial leads, while lead II and V2 didn’t show any ST-segment alteration. Transthoracic echocardiogram was reported to be normal. Due to critical conditions and low likelihood of CAD, angiography wasn’t performed. The clinical course was worsened by occurrence of hyperkalaemia, acute kidney injury, and multiple episodes of ventricular tachycardia evolving in pulselessness electrical activity which required advanced life support. The patient subsequently died due to multi-organ failure, without the possibility of escalation therapy due to his status. SHS is an emerging ECG sign that is reported to be associated with critical conditions (mechanical ventilation, sepsis, bowel perforation) and in the majority of cases it is not related to CAD. It usually occurs in inferior leads (especially in case of abdominal disease) and in precordial leads (pneumothorax, aortic dissection, mechanical ventilation). Our patient had features consistent with previous cases reported in literature and, even if he experienced several episodes of cardiac arrest and blood exams revealed elevated values of cardiac troponin, the typical ECG pattern and the normal echocardiogram suggest SHS instead of ACS, avoiding unnecessary percutaneous coronary intervention. As reported in literature, even if in our case the appearance of this sign was associated with poor prognosis. Conclusions SHS mainly occurs in critically ill patients and is associated with death and poor outcomes. The potential pathophysiological mechanisms are still unclear. It is important to promptly recognize this pattern and differentiate between other causes of ST-segment elevation to select the appropriate therapy according to the setting. This is the first case-report among Italian hospitals of SHS.

409 Not all ST elevation are myocardial infarction: a lesson learned from ‘spiked helmet sign’