A subset of MACE 2 red flags suggest high risk of brain injury with intracranial hemorrhage. If any one of the following red flag signs or symptoms are present, the casualty should be referred urgently for CT scan.

Do not delay evacuation to obtain TBI whole blood biomarkers.

- Deteriorating levels of consciousness or a drop in post injury GCS score by 2 or greater
- Combativeness or agitated behavior
- 2 or more episodes of vomiting
- Witnessed seizure activity
- Focal neurologic deficits such as pupil asymmetry, facial weakness/asymmetry, weakness or paralysis on one side compared to the other
- Bleeding disorder or therapeutic anti-coagulation with heparin, low molecular weight heparin, warfarin, or novel oral anticoagulants (direct thrombin inhibitors and direct factor Xa inhibitors)

In addition, casualties with evidence suspicious for a penetrating brain injury, depressed skull fracture, or signs of a basilar skull fracture (e.g., raccoon eyes, Battle’s sign, otorrhea) should be referred urgently for CT scan.