Escalation must follow the patient's orders and agency policy; the following are representative thresholds.
🚩 Red flags — escalate
An acute focal neurologic deficit — facial droop, arm or leg weakness, speech difficulty, sudden severe headache, sudden vision loss, or sudden confusion (a positive F.A.S.T. / BE-FAST screen) — activate emergency response (911) immediately and record the last-known-well time; this is a time-critical stroke emergency.
An active seizure — protect the patient, and activate emergency response (911) for a seizure lasting more than five minutes, repeated seizures, or status epilepticus.
A sudden, severe “worst headache of life” — activate emergency response (911) for a possible hemorrhage.
A rapidly declining level of consciousness — activate emergency response (911).
Signs of increased intracranial pressure — a worsening headache with vomiting, a declining level of consciousness, or pupil changes — activate emergency response (911).
A new inability to move a limb or a sudden loss of coordination — urgent or emergency evaluation per severity.
