Pickelhaube – Tee-Pee ECG Double Whammy!

A young patient admitted with multiple abdominal and chest gunshot wounds is in shock with multiple electrolyte abnormalities. Initial electrocardiogram (ECG) revealed a dome-and-spike pattern in the inferior leads (Fig. A) resembling a Prussian spiked helmet (Pickelhaube), reflective of severe systemic illness, shock, elevated lactate level and abdomino-thoracic injuries. The anterior leads revealed peaking of the T waves indicative of hyperkalemia in addition to prominent U waves reflective of initial low ionized calcium and low magnesium, giving the appearance of a teepee. Multiple surgeries in addition to electrolyte adjustment resulted in stabilization and resolution of the acute ECG findings (Fig. B).