The VA/DoD Clinical Practice Guideline for concussion and mild traumatic brain injury recommends referral of a patient to an expert if certain findings are present.

Patient selection: concussion or traumatic brain injury, more than 7 days after the event

Indications for immediate referral:

(1) progressively declining level of consciousness

(2) progressively declining (deteriorating) neurological exam

(3) asymmetrical pupils

(4) seizures

(5) repeated vomiting

(6) motor and/or sensory neurological deficits

(7) double vision

(8) worsening headache

(9) cannot recognize people or disoriented to place

(10) slurred speech

(11) unusual behavior


The presence of one or more indicators should prompt an immediate referral.

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