If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.
Adult
Stroke/transient ischaemic attack (TIA)
- Patient with acute neurological symptoms of a stroke; multiple/crescendo TIA
- New acute symptoms
Progressive loss of neurological function
- Acute onset severe:
- ataxia
- vertigo
- visual loss
- Acute severe exacerbation of known MS
Seizures/epilepsy
- Status epilepticus/epilepsy with concerning features:
- first seizure
- focal deficit post-ictally
- seizure associated with recent trauma
- persistent severe headache > 1 hour post-ictally
- seizure with fever
Headache/migraine
- Headache with concerning features:
- sudden onset/thunderclap headache
- severe headache with signs of systemic illness (fever, neck stiffness, vomiting, confusion, drowsiness)
- first severe headache age > 50 years
- severe headache associated with recent head trauma
- recent onset headaches in young obese females
- headaches with papilledema
- >50 years with raised CRP/ESR or if giant cell arteritis or vasculitis suspected
Movement disorders
Other referrals to emergency
- Altered level of consciousness
- Bilateral limb weakness with or without bladder and/or bowel dysfunction
- Acute rapidly progressive weakness (Guillain-Barre Syndrome, myelopathy)
- Delirium/sudden onset confusion with or without fever
Paediatric
Seizures/epilepsy
- New onset seizures that require emergency care/advice
- Status epilepticus (convulsive or non-convulsive)
- Developmental/cognitive/psychiatric regression accompanying new onset or ongoing epileptic seizures
- New onset seizure with new neurological deficit (e.g. focal weakness, speech impairment, cognitive impairment) – call 000 for emergency assessment for stroke and transport to the Emergency Department
- Specific seizure types with epileptic encephalopathy risk e.g. infant with possible epileptic spasms
- High initial seizure burden (>5 seizures, before first AED), excluding typical absence seizures
- Neonate / infant (<12-month-old) with epileptic seizure onset
Headaches/migraine
- Headache with papilledema or change in vision/double vision (excluding established migraine with visual aura) or new neurological examination findings (e.g. sixth nerve palsy, gait disturbance, focal weakness)
- Headaches that wake at night or headaches immediately on wakening
- New severe headaches
- Sudden onset headache reaching maximum intensity within 5 minutes (= explosive onset)
- Focal neurological features
- Associated with significant persisting change of personality or cognitive ability or deterioration in school performance
Functional neurological symptoms
- The patient is unable to mobilize safely or has frequent falls/seizure like attacksAddition
Movement disorder
- Abrupt onset or deterioration of a movement disorder
- Acute onset of ataxia / chorea
- Impairment of function i.e. walking, attend school
Hypotonic infant
- Tachypnoea (signs of respiratory distress such as accessory muscle use are NOT seen in patients with neuromuscular disorders)
- Feeding difficulties with weight loss
Gait abnormality, isolated motor delay or focal weakness
- Acute onset of (or rapidly progressive) weakness e.g. Guillain Barre syndrome, transverse myelitis
- Acute onset focal weakness (suspected stroke – call 000)
- Breathing difficulties (NB tachypnoea may be the only sign of respiratory distress in a child with a neuromuscular condition)
- Feeding or swallowing difficulties
- Acute foot drop or acute onset focal neuropathy
Stroke
- Acute stroke – call 000 and request urgent transfer (timelines apply for t-PA and thrombectomy for embolic/thrombotic stroke)
Other neurological conditions
- Developmental/ intellectual impairment or behavioural / psychiatric disorders with regression
- Acute encephalopathy, acute confusional state, altered level of consciousness