Signs or Symptoms of Pathology (Red Flags)

Clinical Cornerstone: Consider asking additional questions that help evaluate for the presence of red flags in concussion. Red flags are symptoms or signs that may indicate a serious pathology and should be deliberated in the clinician’s differential diagnosis.

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• Spinal fracture

  • Red flags include: history of osteoporosis, corticosteroid use, severe trauma or dangerous mechanism, female sex, older age, history of spinal fracture, history of cancer, history of falls, ≥65 years of age, paresthesia in extremities, inability to actively rotate the neck 45 degrees to the left and right, midline tenderness on palpation (Canadian C-Spine Rule).

  • Action: to appropriate provider for immediate imaging.

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• Intracranial/Brain Lesion

  • Red flags include: sudden and intense onset headache (thunderclap headache), seizure, vomiting (two or more episodes), nystagmus, new difference in pupil size, falls due to imbalance, extreme drowsiness, slurred speech, unusual confusion or irritability or behaviors, anterograde amnesia (<30 minutes). (Canadian CT Head Rule)

  • Action: Refer to an appropriate provider.

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• Vertebral/Carotid Artery Dissection

  • Red flags include: severe neck pain and/or headache (described as the worst pain ever), double vision, difficulty initiating swallowing, dizziness, drop attacks, facial numbness, difficulty walking, nausea, nystagmus.

  • Action: Immediate emergency referral.

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• Cranial Fracture

  • Red flags include: history of osteoporosis, corticosteroid use, severe trauma or dangerous mechanism deformity, female sex, older age, history of spinal fracture, history of cancer, history of falls, ≥65 years of age, severe headache, signs of basal fracture (leakage of fluids from ears or nose, “racoon eyes”, Battle’s sign). (Canadian CT Head Rule).

  • Action: Immediate emergency referral.

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• Spinal Malignancy

  • Red flags include: history of cancer, unexplained weight loss, unexplained significant night sweats, pains worse at night, progressive headaches worse with exertion.

  • Action: Refer to an appropriate provider.

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• Cervical Myelopathy

  • Red flags include: gait disturbances, hand clumsiness, non-dermatomal numbness, weakness or numbness and weakness involving lower extremity / bowel / bladder, coordination problems.

  • Action: Immediate emergency referral.

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• Meningitis

  • Red flags include: neck stiffness, severe generalized headache that is worse with flexion, neck pain or headache with fever or  vomiting or rash,  altered mental status, photophobia.

  • Action: Immediate emergency referral.

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• Neurological disorders (e.g., MS, ALS, neurodegenerative disorders)

  • Red flags include: upper/lower motor neuron findings, clonus.

  • Action: Refer to appropriate provider.