<keypoints>
- Red flags indicate possible structural brain or cervical spine injury requiring **emergency department referral**
- Key red flags: prolonged or deteriorating consciousness, seizures, repeated vomiting, worsening headache, pupillary asymmetry, focal neurological deficits, severe neck pain
- Higher-risk populations (age ≥65, anticoagulant use) have a lower threshold for concern, particularly for intracranial bleeding
- Any person who is not lucid or fully conscious should be assumed to have a more severe TBI or cervical spine injury until proven otherwise
</keypoints>
Red Flags Requiring Emergency Referral
The following warrant immediate emergency department assessment, as they may indicate structural brain injury (e.g. intracranial bleeding) or cervical spine injury:
Consciousness and Cognition
- Prolonged loss of consciousness (≥2 minutes), or any deterioration in conscious state
- Inability to recognise people or places
- Increasing confusion, restlessness, agitation, or combativeness
- Excessive drowsiness or inability to be woken
Neurological
- Seizures or convulsions
- Pupillary asymmetry (one pupil larger than the other)
- Dysarthria (slurred speech)
- Weakness, tingling, or numbness in arms or legs
- Ongoing diplopia or other significant visual disturbances
Other Physical Signs
- Severe or worsening headache
- Repeated vomiting (>1 episode in adults; any vomiting in children)
- Severe neck pain or midline cervical tenderness
- Ongoing severe dizziness/vertigo
- Significantly unusual or inappropriate behaviour / personality changes