The Nonspecific Camel-Hump Sign

Joseph A. Abbott, MD, Melvin D. Cheitlin, MD

THE ELECTROCARDIOGRAPHIC then complete ventilatory support. Subse¬ preinjury ECG tracing was available for
"camel-hump" sign of Osborn,1 a term quently, cardiac arrest occurred, and he re¬ comparison. Although these ECG changes
first proposed by Harvey, is generally sponded to closed-chest cardiac massage are consistent with hypothermia, the pa¬

considered specific for hypothermia.2 and intravenous injection of 20 mEq of so¬ tient was never hypothermie." On the sec¬
dium bicarbonate; direct-current cardie- ond postoperative day, a second cardiac ar¬
However, we recently saw a patient version was not necessary. Analysis of rest occurred, and the patient died.
who had such a finding resulting not
blood gases after resuscitation disclosed Postmortem examination showed exten¬
from hypothermia but from massive metabolic acidosis (pH, 7.26; Pao2, 268 mm sive cerebral injury, including hemor-
cerebral injury, indicating that this Hg; Paco2,42 mm Hg), and an ECG (Figure) rhagic changes and ecchymoses, especially
sign is nonspecific. To our knowledge, demonstrated a slow heart rate, a pro¬ prominent over the left fronto-occipital re¬
this is the second instance of central longed PR interval, peaked T waves, a long gion. Cardiac examination disclosed no evi¬
nervous system disease resulting in QT interval, and the camel-hump sign. No dence of myocardial contusion, valvular
the camel-hump wave3 (or, more accu-
rately, dromedary wave) and the first
with postmortem confirmation.
Report of a Case
An 8-year-old boy sustained a severe
head injury when struck by a motorcycle
while riding his bicycle. His growth and
development had been normal. On admis-
sion, he was deeply comatose, and the pu-
pils were fixed, dilated, and unresponsive
to light; no papilledema was present. The
blood pressure was 122/80 mm Hg and the
pulse was 140 beats per minute and regu-
lar. There were left temporal ecchymoses
and lacerations of the chin and right leg.
The hematocrit reading was 34%, and hy-
percapnia with mixed respiratory and
metabolic acidosis was present. Because of
ventilatory insufficiency, trachéal intuba¬
tion and assisted ventilation were re¬
quired; metabolic acidosis was corrected by
infusions of sodium bicarbonate. A six-
bur-hole craniotomy performed within one
hour of admission revealed severe cerebral
edema, cerebral contusions, and bilateral
subdural hematomas, which were evac¬
uated. Postoperative cerebral angiography
showed no evidence of extracerebral
spaces or shift in vascular structures. His
pupils decreased in size and became re¬ QRS wave is followed by a contiguous
sponsive to light, but the depth of the coma hypothermie hump most pronounced
did not abate, and he required assisted and in leads II, III, aVp, and V3 through V6. T
wave is also peaked in these leads.

From the University of California Medical Ser-

vice, San Francisco General Hospital, San Fran-
cisco.
Reprint requests to the Cardiopulmonary Unit,
San Francisco General Hospital, 1001 Potrero
Ave, San Francisco, CA 94110 (Dr Abbott).

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rupture, myocardial infarction, cononary
artery disease, or congenital abnormal¬
ities.
Comment
Disease of the central nervous sys¬
tem is well recognized as effecting
changes in the ECG.8 DeSweit3 was
first to note that a subarachnoid hem¬
orrhage could result in ECG changes
that simulated hypothermia; his pa¬
tient, a 60-year-old woman, had a
subarachnoid hemorrhage from which
1. Osborn JJ: Experimental hypothermia: Res-
piratory and blood pH changes in relation to car-
diac function. Am J Physiol 175:389-398, 1953.
2. Fernandez JP, O'Rourke RA, Ewy GA:
Rapid active external rewarming in accidental
hypothermia. JAMA 212:153-156, 1970.
3. DeSweit J: Changes simulating hypother-
latrogenic Skull Fracture
By Use of a Head Clamp
Michael P. Biber, MD
Fig 1 .—Lateral view of skull showing midparietal horizontal fracture (arrows) extending
from close to coronal suture to region of lambdoid.
Downloaded from www.jama.com by guest on April 29, 2010
she subsequently recovered. DeSweit
speculated that hypothalamic involve¬
ment resulted in sympathetic stimu¬
lation and was responsible for the
"remote" effect of the central nervous
system on the heart. Our patient suf¬
fered from massive cerebral trauma,
had a normal heart (confirmed by
postmortem examination), and was
never hypothermie. Although we can¬
not exclude with certainty that the
ECG abnormalities did not result
References
mia in the electrocardiogram in subarachnoid
hemorrhage. J Electrocardiol 5:193-195, 1972.
4. Travino A, Razi B, Beller BM: The charac-
teristic electrocardiogram of accidental hypother-
mia. Arch Intern Med 127:470-473, 1971.
5. Clements SD Jr, Hurst JW: Diagnostic
value of electrocardiographic abnormalities ob-
Depression
from the effects of resuscitation,
metabolic acidosis, sodium bicarbon¬
ate injection, or electrolyte imbal¬
ance, we can be certain that the
camel-hump sign is not specific for
hypothermia. Indeed, Osborn1 be¬
lieved that the ECG manifestation of
hypothermia is a reflection of acidosis
rather than of hypothermia per se.
The camel-hump sign has also been
reported in normal subjects without
acidosis.7
served in subjects accidentally exposed to cold.
Am J Cardiol 29:729-734, 1972.
6. Abildskov JA, Millar K, Burgess MJ, et al:
The electrocardiogram and the central nervous
system. Prog Cardiovasc Dis 13:210-216, 1970.
7. Rothfeld EI: Hypothermic hump. JAMA
213:626, 1970.
SKULL roentgenograms are ob-
tained in most cases of severe head
trauma reaching emergency medical
facilities. This practice persists de-
spite evidence of the questionable
value of these studies in patients not
reasonably suspected of having de-
pressed fractures or foreign body
penetration of scalp or skull.1,2
When the head trauma victims are
young children or infants unable to
cooperate with diagnostic roentgen-
ographic procedures, adequate films
often require head fixation. Metal
foam-padded head clamps are now
commonly used for head immobiliza-
tion during routine roentgenography
as well as radioisotope brain scan-
ning.3
We report a case in which depres-
sion of a fracture edge shown by an
anteroposterior roentgenogram was
caused by lateral head-compression
applied by means of a standard re-
From the Neurological Unit, Boston City Hos-
pital, and the Department of Neurology, Harvard
Medical School, Boston.
Reprint requests to Neurological Unit, Beth Is-
rael Hospital, 330 Brookline Ave, Boston, MA
02215 (Dr Biber).