Version July 2025
INTRODUCTION —
In almost every resource-abundant country, the proportion of people over 60 years of age is growing faster than any other age group because of longer life expectancy and declining birth rates [1]. As a result, more older individuals are presenting to emergency departments following trauma [2]. In addition, advances in the care of chronic diseases have increased the number of older adults with active lifestyles, which predispose them to injury [3].
Although trauma remains a leading cause of morbidity and mortality across all ages, older adults differ significantly from their younger counterparts in their greater number of comorbidities [4,5], and higher risk of severe disability and death [6,7]. Older adult patients are more susceptible to injury from minor mechanisms and less able to compensate from any injury. To manage their chronic ailments, older adult patients are more likely to be taking multiple medications, some of which may blunt their response to the physiologic stress of trauma and increase their risk for complications [8].
This topic will review the initial assessment and management of trauma in older adult patients. Detailed discussions of trauma care and the management of specific injuries are found separately:
●Emergency trauma management (see "Initial management of moderate to severe hemorrhage in the adult trauma patient" and "Approach to shock in the adult trauma patient" and "Emergency ultrasound in adults with abdominal and thoracic trauma")
●Head, neck, and spine trauma (see "Management of acute moderate and severe traumatic brain injury" and "Acute traumatic spinal cord injury" and "Suspected cervical spine injury in adults: Choice of imaging" and "Cervical spinal column injuries in adults: Evaluation and initial management" and "Thoracic and lumbar spinal column injury in adults: Evaluation")
●Chest trauma (see "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of penetrating thoracic trauma in adults" and "Initial evaluation and management of chest wall trauma in adults" and "Initial evaluation and management of rib fractures" and "Initial evaluation and management of blunt cardiac injury")
●Abdominal trauma (see "Blunt abdominal trauma in adults: Initial evaluation and management" and "Initial evaluation and management of abdominal stab wounds in adults" and "Abdominal gunshot wounds in adults: Initial evaluation and management")
●Pelvic and genitourinary trauma (see "Pelvic trauma: Initial evaluation and management" and "Minor pelvic fractures (pelvic fragility fractures) in the older adult" and "Blunt genitourinary trauma: Initial evaluation and management")
●Extremity trauma (see "Severe upper extremity injury in the adult patient" and "Severe lower extremity injury in the adult patient")
DEFINITION —
Debate continues regarding the exact age at which a trauma patient should be considered an older adult, with some suggestions starting as low as 50 [9]. One large observational study showed increased mortality, adjusted for injury severity, starting at age 70, suggesting this age is an appropriate cutoff for defining the older adult population [9]. As most studies use 65 as the threshold to define the geriatric patient or older adult (albeit often without providing evidence to support that choice), we too will use this age for the purposes of the following discussion.
It is likely more important to consider the patient's age in the context of their overall health when determining their relative risk of injury following trauma than to consider age alone [10]. Observational studies suggest that frail older trauma patients fare worse than their healthier counterparts of the same age and that pre-existing comorbidities may be more important than chronologic age [11-14].
EPIDEMIOLOGY AND MECHANISMS OF INJURY —
Falls and motor vehicle crashes are the most common mechanisms of injury among older adults. However, most importantly, older adult trauma patients experience higher mortality than their younger counterparts regardless of the mechanism involved [7,15,16]. Up to one-third of all older adult patients presenting with an Injury Severity Score greater than 15 can be expected to die while in the hospital.
●Falls – Falls are the most common cause of injury in patients over the age of 65, accounting for nearly three-quarters of all trauma in this population [15,17]. According to a systematic review of 18 studies, the probability of falling at least once in any given year for individuals 65 years and older is approximately 27 percent [18]. In the United States, nearly 28 percent of adults aged 65 and over fall every year [19], and age-adjusted mortality from falls in older adults increased from 2000 to 2016 [20]. Older adult patients requiring emergency department evaluation for a fall are at high risk for recurrence with one study reporting a readmission rate of 14.4 percent for patients initially admitted for a fall-related injury [21]. Falls in older adults most often occur from a standing position on a level surface, with orthopedic injury (eg, hip or long bone fracture) the most common significant complication. Despite the seemingly benign mechanism in many cases, falls can lead to dire medical and economic consequences for older adult patients, including the need for tracheal intubation or blood transfusion, cervical spine or thoracic injury, and death [5,15,22,23]. Falls in older individuals are discussed in detail separately. (See "Falls in older persons: Risk factors and patient evaluation".)
●Motor vehicle collision – Motor vehicle collisions are the second most common mechanism of injury among older patients, and the most common cause of traumatic mortality [5,15,24]. Approximately one-quarter of all older adult victims of motor vehicle crashes sustain a chest injury (most often rib fractures), which can exacerbate pre-existing cardiopulmonary and other disease and increases the risk of significant complications, including pneumonia and respiratory failure [25,26]. Older adults are second only to children as victims of automobile-pedestrian accidents, but account for the largest percentage of the auto-pedestrian fatalities [15,27-30]. The highest mortality rate in geriatric trauma is among pedestrians struck by a vehicle.
●Fractures – With all types of blunt trauma, older adults are more likely to sustain injuries of all types, particularly fractures, than their younger counterparts [5,31-33]. Based largely upon retrospective data, it appears that fractures of the spine (especially of the cervical spine), ribs, hip, and extremities are among the injuries more likely to occur in older patients. (See 'Common and high-risk injuries' below.)
●Burns – Burns can have a devastating effect on older adults, in whom mortality is significantly higher for any size burn than in younger adults [34,35]. The authors of a retrospective study of a predictive model for older adult burn patients reported that the median lethal dose (LD50) for patients aged 60 to 70 was 43.1 percent total body surface area (TBSA) burned, for those aged 70 to 80 the LD50 was 25.9 percent TBSA, and for those 80 and older the LD50 was only 13.1 percent TBSA [34]. (See "Emergency care of moderate and severe thermal burns in adults".)
●Assault and abuse – While assaults and penetrating trauma are less common in older adults, they are associated with higher morbidity and longer hospital stays than that experienced by younger adults [36,37]. Clinicians should always consider the possibility of older adult abuse and suicide attempt when caring for older trauma victims. (See "Elder abuse, self-neglect, and related phenomena".)
CLINICAL ANATOMY AND PATHOPHYSIOLOGY —
A number of the anatomic and physiologic changes that accompany aging place the geriatric trauma patient at greater risk of injury and death and impair their capacity to respond to the stress of severe injury. The physiology of aging is discussed in detail separately, but changes of particular relevance to trauma and their implications are briefly described below and summarized in the following table (table 1 and table 2). (See "Normal aging" and "Immune function in older adults".)
Older adults have reduced vital capacity, inspiratory capacity, and forced expiratory volume, which diminishes respiratory reserve and limits the ability to tolerate even seemingly minor trauma [17,38]. Responses to hypoxia, hypercarbia, and acidosis are often blunted in older adults [39]. In addition, they are less able to compensate for metabolic disturbances and more likely to present with a normal respiratory rate despite becoming progressively hypoxic and hypercarbic, making clinical assessment challenging [40].
The myocardium of older adults becomes stiffer, compromising cardiac output, and less sensitive to catecholamines, which often results in a less profound tachycardic response to hemorrhage, pain, or anxiety following trauma. The absence of an absolute tachycardia due to this blunted response may create a false sense of security among clinicians. Systemic vascular resistance is increased, often contributing to baseline hypertension, which can lead to the misinterpretation of blood pressure readings following trauma when expected declines may not manifest despite the onset of shock. Put another way, the values that should be considered abnormal for vital signs are different in older patients. As an example, according to a large retrospective review of geriatric blunt trauma patients, heart rates above 90 beats per minute and systolic blood pressure less than 110 mmHg correlate with increased mortality in this population. Among younger trauma patients, comparable increases in mortality are not seen until the heart rate reaches 130 beats per minute and systolic blood pressure drops below 95 mmHg [41].
In older patients, the dura adheres tightly to the skull and bridging veins become stretched, thereby increasing the risk of subdural hemorrhage from head injury, while potentially reducing the risk of epidural hemorrhage. In addition, there is approximately a 30 percent reduction in brain size between the ages of 30 and 70 [42]. This brain atrophy increases the space in which blood can accumulate and may delay the development of symptoms and signs associated with intracranial hemorrhage. In some older adults, dementia complicates medical assessment following trauma. Cerebrovascular autoregulation declines with age, making the brain potentially more susceptible to injury during periods of systemic hypotension [43]. (See 'Head injury' below.)
Lower bone density and compliance results in increased risk for all types of fractures, particularly those of the hip, vertebra, and wrist [44]. Rib fractures are more common and associated with higher complication rates. (See 'Cervical spine injury' below and 'Chest trauma' below and 'Musculoskeletal injuries of the pelvis, hip, and extremities' below.)
AGE-RELATED RISK FACTORS
Medication and disease-related — Older individuals are more likely to have chronic disease and to take multiple medications to manage these ailments. Medications that pose special risks to the older adult trauma patient include anticoagulants, antiplatelet agents, beta blockers, calcium channel blockers, and glucocorticoids. Preinjury beta blockade has been shown to increase the odds of death, likely due to the masking of normal physiologic responses to shock [45]. Chronic glucocorticoid use, as might be seen in patients with chronic obstructive pulmonary disease, also increases mortality in trauma [46].
Drug metabolism is altered in older adults. The increase in total body fat and reduction in lean body mass that occurs with aging increases the volume of distribution of many medications, which can prolong their duration of effect. Declines in liver and kidney function alter the metabolism and elimination of many medications. These changes not only complicate the management of older trauma patients but also increase their risk for sustaining trauma, as found in a meta-analysis published in 2009 that reported a strong association between the use of benzodiazepines, sedative-hypnotics, and antidepressants and falls in older adults [47]. The addition of any medication is associated with a significant increase in the risk of falls among older adult patients [48]. (See "Falls in older persons: Risk factors and patient evaluation".)
Although hypertension and heart disease are the most common pre-existing conditions among older adult trauma patients, hepatic disease (particularly cirrhosis), chronic kidney dysfunction, and cancer confer the greatest mortality risk of all comorbid medical conditions [49]. In addition, decompensated (congestive) heart failure increases mortality substantially, particularly in patients taking anticoagulants, beta blockers, or both [50].
Impact of frailty — Among older adults, evidence suggests that frailty may be a better predictor of both short- and long-term morbidity and mortality following trauma than age alone. Several scores intended to provide insight into patient frailty and its impact on trauma outcomes have been developed [51]. The Trauma-Specific Frailty Index (TSFI) is one example of a validated measure that uses a combination of comorbidities, daily activities and function, health attitude, and nutrition to create a frailty score (table 3). In a prospective, multicenter, observational study of 1321 geriatric trauma patients (mean age 77), the TSFI was an independent predictor of worse outcomes, as patients categorized as frail (n = 494) had significantly higher mortality (odds ratio [OR] 1.93, 95% CI 1.12-3.32) and major complications (OR 3.55, 95% CI 2.26-5.57) compared with their nonfrail counterparts [52]. In a small, retrospective study, use of a modified TSFI score was associated with lower 30-day readmission rates compared with the Emergency Severity Index [53]. Although the clinical implications of frailty assessment have yet to be described completely, such assessment may be a useful tool when determining disposition and follow-up for older adult trauma patients.
ASSESSMENT AND INITIAL INTERVENTIONS
Problem of under-triage — Traditional physiologic parameters used to identify high-risk trauma patients, such as systolic blood pressure below 90 mmHg or heart rate above 120 beats per minute, do not account for the declining physiologic capacities of older adults. Although there is limited prospective data to guide triage decisions about geriatric trauma patients, given the increased risk for severe injury and death in this population, we suggest maintaining a lower threshold for trauma team activation for any patient over the age of 70 [54,55]. Whenever possible, such patients should be evaluated at a trauma center with trauma team activation, keeping in mind that even seemingly minor mechanisms (ie, falls from standing) may cause severe injury and often warrant such activation. Multiple large, observational studies support this approach [9,56,57]. At remote hospitals or in resource-limited settings, it is prudent to obtain consultation with a trauma center about management and potential transfer, depending on the clinical circumstances.
In addition, we concur with guidelines published by the United States Centers for Disease Control (CDC) calling for direct transport to a trauma center whenever possible for any patient 65 or older with a systolic blood pressure <110 mmHg [58]. We also believe it is reasonable to use a pulse of 90 or above as the threshold defining tachycardia, which may be a sign of hemorrhage or significant injury warranting careful investigation. We make these suggestions in the hope of helping clinicians to avoid under-triage, which is a significant problem in the management of geriatric trauma patients [59].
Multiple observational studies demonstrate the problem of under-triage [56,60-63]. As an example, one retrospective study of 26,565 trauma patients reported an under-triage rate of 49 percent in patients older than 65 [60]. Under-triage may be due in part to lack of recognition that older adult patients are at greater risk of injury and in part to traditional triage tools (eg, vital signs, mechanism of injury, or the American College of Surgeons Committee on Trauma triage criteria) that may be relatively insensitive for signs of injury in older patients. The impact of insensitive triage criteria are supported by several retrospective studies, including a review of 51,227 adult trauma cases in which many of the classic physiologic criteria used for trauma team activation, such as blood pressure and heart rate, failed to predict hospital mortality in geriatric trauma patients [56,61]. In this study, trauma team activation occurred significantly less often for older adult patients (14 versus 29 percent) despite a similar percentage of severe injuries (defined as Injury Severity Score >15). Under-triaged older adults injured from ground-level falls have a higher mortality rate than younger adults injured from more severe mechanisms and evaluated by a trauma team [64]. It is likely that under-triage has multiple causes. Some researchers suggest that inadequate training of clinicians and age bias contribute to the problem [65,66].
Under-triage is particularly concerning given studies that show improved outcomes when older adult patients with significant injuries are taken to level one or level two trauma centers [67]. In addition, advancing age is associated with an increasing risk of death even among minimally injured patients, according to another large retrospective study [59].
Another problem in geriatric trauma is the implementation and consistent use of appropriate triage criteria. In an observational study comparing the periods before and after geriatric trauma criteria were introduced to a state emergency medical services (EMS) system, researchers found that the proportion of older adults meeting the criteria for trauma center transport increased substantially after the introduction, but no actual increase in trauma center transports occurred [68].
History — It is important to obtain a precise history whenever possible, although this can be challenging with some older adult trauma patients. A general discussion of the history in adult trauma is found separately. (See "Initial management of trauma in adults" and "Secondary survey (evaluation) of the adult trauma patient", section on 'History'.)
In addition to standard inquiries about events and mechanism, important questions to ask older patients (or their family members, EMS personnel, or others who may have insight) include:
●Preliminary events – What happened immediately before the trauma (eg, altered consciousness, difficulty breathing, change in vision)?
●Medications – What medications is the patient taking (eg, anticoagulant, antiplatelet, beta blocker, calcium channel blocker)?
●Comorbidities – What pre-existing medical conditions does the patient have (eg, cardiovascular or kidney disease, diabetes)?
●Baseline function – What was the patient's baseline level of motor and cognitive function prior to the traumatic event?
●Advanced directives – Does the patient have a written advanced directive, Medical Orders for Life-Sustaining Treatment (MOLST), or a health care proxy that may be useful for determining the goals of care? (See "Advance care planning and advance directives".)
Prehospital management — EMS providers should understand that minor trauma, such as falls from standing and minor motor vehicle accidents, can cause significant injuries and even death in older adults. We suggest that trauma patients over the age of 70 be evaluated at a trauma center whenever possible, regardless of the mechanism of injury [69]. (See 'Problem of under-triage' above.)
In addition to the relatively common injuries sustained in trauma, older adult patients are more likely to sustain otherwise rare injuries, such as C1 or C2 cervical spine fractures, which may result from a simple fall onto a hard surface. At the same time, older adult patients do not tolerate standard cervical spine motion restriction procedures as well as their younger counterparts. While there are no hard and fast rules, provider judgment may be needed to determine when spinal motion restriction is necessary and how this can best be accomplished. This might entail allowing for slight (<30 percent) elevation of the head of the bed or foregoing a rigid backboard or cervical collar.
Based upon evidence of increased morbidity and mortality among older trauma patients, a number of specialists advocate transport to a trauma center and activation of the trauma team based solely upon patient age regardless of the mechanism of injury [56,59,70]. As an example, one retrospective observational study of 883 trauma patients aged 70 or older reported a mortality rate of 16 percent among the 660 "stable" patients who did not meet any standard trauma team activation criteria [56]. Another retrospective cohort study of 87 older adults with significant pelvic fractures reported a lower complication rate among those transported directly to a level one trauma center compared with those brought to a nontrauma center [71].
Nevertheless, evidence about the appropriate transport and evaluation of older trauma patients is limited and other groups use different criteria. As an example, the American College of Surgeons recommends transport to a designated trauma center for trauma patients over the age of 55 regardless of mechanism or apparent severity [72].
Primary survey
Overview — The standard primary survey is appropriate for the management of older trauma patients and is reviewed in detail separately. Issues of special importance in older trauma patients are discussed here (table 2). Although older trauma patients are at increased risk of death and disability, many respond well to resuscitative measures and aggressive management is appropriate [73,74]. Of note, blunted responses to hypoxia, hypercarbia, and acidosis can delay clinical signs of distress in older trauma patients. Therefore, providers should assume that serious injuries are likely to be present even when concerning clinical findings are not apparent initially. (See "Initial management of trauma in adults", section on 'Primary evaluation and management' and "Normal aging", section on 'Respiratory system'.)
Airway and breathing — When performing the primary survey in an older adult trauma patient, clinicians should look for airway anomalies that are likely to complicate management, such as limited mouth-opening (temporomandibular arthritis) and dentures. Laryngoscopy and intubation are more difficult in patients with limited mouth-opening. Bag mask ventilation may be more difficult once dentures are removed; intact dentures should be kept in place should assisted ventilation become necessary. Older adults have limited respiratory reserve, making early administration of supplemental high-flow oxygen of greater importance. According to one retrospective study of geriatric trauma patients, a respiratory rate below 10 breaths per minute is associated with a greater risk of death [75]. (See "Basic airway management in adults" and "Rapid sequence intubation in adults for emergency medicine and critical care", section on 'Preoxygenation'.)
Diminished respiratory reserve often prevents older adults from compensating adequately for chest injuries. Early aggressive airway management, including tracheal intubation, may be necessary. Should rapid sequence intubation be required, the doses for drugs that may cause hemodynamic compromise, such as benzodiazepines, barbiturates, and even etomidate, should be reduced between 30 and 50 percent to minimize the risk of cardiovascular depression. (See "Rapid sequence intubation in adults for emergency medicine and critical care" and "Airway management in the geriatric patient for emergency medicine and critical care" and "Overview of advanced airway management in adults for emergency medicine and critical care".)
Older adults are at greater risk of decompensation during the peri-intubation period. Physiologic optimization may be necessary to reduce such risk, particularly in patients with hemodynamic instability or hypoxemia. Approaches to optimization are reviewed in detail separately. Common conditions that cause or exacerbate hypotension and hypoxemia during the peri-intubation period and interventions to help prevent or manage them are summarized in the following tables (table 4 and table 5). (See "The physiologically difficult airway: Optimization of airway management in adults at risk of decompensation for emergency medicine and critical care".)
Although evidence is scant, older trauma patients not in need of immediate intubation but suffering from some respiratory difficulty may benefit from noninvasive positive pressure ventilation. In one prospective observational study of 22 patients with blunt thoracic trauma, use of noninvasive bilevel positive pressure ventilation substantially improved gas exchange and vital signs enabling 18 patients to avoid tracheal intubation [76]. (See "Noninvasive ventilation in adults with acute respiratory failure: Benefits and contraindications".)
Circulation
Vital signs may be unreliable — "Normal" vital signs in geriatric trauma patients may be substantially different from their younger counterparts, and recognizing early shock can be more difficult. Baseline hypertension is common among older patients and in the setting of trauma may contribute to a false sense of comfort on the part of clinicians when a blood pressure in the "normal" range actually represents relative hypotension. Thus, trends of vital signs are likely to be more useful than any individual measurement. Repeat measurements should be obtained frequently and all readings interpreted in light of the patient's baseline and previous readings.
The effect of medications the patient takes regularly can further obscure the meaning of vital sign measurements. Beta blockers and other antihypertensive medications commonly taken by older adults can blunt the normal tachycardic response to hemorrhagic shock. This effect is compounded by the decreased sensitivity of older myocardium to circulating catecholamines. (See 'Clinical anatomy and pathophysiology' above.)
Multiple studies demonstrate that vital signs in older trauma patients can be unreliable. According to one retrospective study, mortality increases among older trauma patients when their heart rate rises above 90 beats per minute and systolic blood pressure falls below 110 mmHg, while the same increase in mortality is not evident in younger patients until heart rates reach 130 beats per minute and systolic blood pressure falls below 95 mmHg [41]. Another study found evidence of tissue hypoperfusion despite "normal" blood pressures in older adult trauma patients without isolated head injury [77].
Assessment for shock — A narrowed pulse pressure suggests traumatic shock [78]. Older adults who are unable to compensate for shock by increasing their heart rate or stroke volume, do so by increasing peripheral vascular resistance, often leading to a narrowed pulse pressure.
Given that vital signs may be an unreliable guide to hemodynamic status in older adults, it is important to look for signs of shock in patients who would otherwise be considered "normotensive." Signs such as subtle alterations in mental status (eg, mild confusion, somnolence, or agitation), mild tachypnea, delayed capillary refill, and low urine output may reflect hypoperfusion and early shock. (See "Approach to shock in the adult trauma patient".)
Using ultrasound as part of the primary survey to look for evidence of internal hemorrhage in older patients, who may not manifest signs of shock, is a sound approach (algorithm 1). Ultrasound is both sensitive and specific for detecting significant hemoperitoneum in blunt trauma and is useful for detecting pneumothorax. In addition, skilled sonographers may find ultrasound helpful for identifying cardiac dysfunction. Serial examinations improve the sensitivity and accuracy of ultrasound. (See "Emergency ultrasound in adults with abdominal and thoracic trauma".)
Other tools that can help to identify hypoperfusion and shock in older adults include serial diagnostic testing using a blood lactate concentration or a venous or arterial blood gas. (See 'Diagnostic testing' below.)
Aggressive resuscitation is appropriate for the initial treatment of older adult trauma patients with hypotension or signs of hypoperfusion. However, pre-existing conditions such as ischemic heart disease, heart failure, or kidney dysfunction can cause older adult patients to decompensate from excessive fluid administration or blood loss. Therefore, it is reasonable to begin transfusing blood products early if hypotension or signs of hypoperfusion exist, even before any crystalloid is infused. Standard ratios for transfusion of blood products are appropriate and effective in older adult trauma patients [79]. Transfusion for trauma patients with severe bleeding is discussed separately. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient".)
While hemorrhage remains the most important cause of shock in older trauma patients, clinicians should be aware of other potential causes, including myocardial ischemia and pneumothorax. (See "Approach to shock in the adult trauma patient".)
As with all trauma patients, excessive crystalloid administration may be harmful. The potential benefit of permissive hypotension, and how best to define hypotension, has not been clearly established in the older trauma patient.
Disability — Obtaining an accurate assessment of neurologic function can be difficult in older trauma patients. Such patients can sustain a significant intracranial injury (eg, subdural hemorrhage) and yet manifest no neurologic deficits during their initial examination [80]. Furthermore, performing the examination can be complicated by comorbidities such as underlying dementia or changes such as reduced sensation that are part of normal aging. (See "Normal aging" and "The mental status examination in adults" and "The detailed neurologic examination in adults".)
Monitoring — Particularly in older trauma patients, who may not manifest obvious signs of injury, close monitoring is essential. Monitoring should include serial examinations, including vital signs, mental status, and reassessment of any areas of concern. There is inadequate evidence to support firm guidelines, and the frequency and intensity of re-evaluation will vary depending upon the baseline health of the patient, the clinical scenario, and available resources. As a general guideline, we suggest that a relatively healthy 70 year old without an apparent severe internal injury but who was involved in significant trauma (eg, motor vehicle collision) receive a focused reassessment approximately every five minutes while the primary and secondary surveys are performed, every 15 minutes during the first hour after the surveys are completed, and hourly thereafter until the patient is discharged or admitted, and assuming no problem arises while in the emergency department.
In addition to a cardiac monitor and pulse oximeter, we suggest using an end-tidal CO2 monitor for any older patient with the potential for respiratory problems. This may include patients complaining of mild shortness of breath or those who sustained a seemingly minor fall with a possible chest wall injury. (See "Carbon dioxide monitoring (capnography)" and "Initial evaluation and management of chest wall trauma in adults".)
Secondary survey — Older individuals have decreased pain perception and may have difficulty localizing the pain they do experience, which increases their risk for occult injuries [50]. Thus, the clinician must perform a thorough systematic secondary survey in all older trauma patients. A detailed description of the secondary survey is provided separately; elements of particular importance in older adult patients are discussed here. A checklist to assist with this evaluation is provided (table 6). (See "Secondary survey (evaluation) of the adult trauma patient".)
Older adult patients have a limited capacity to compensate for the physiologic stress of injury, and the secondary survey should focus on detecting signs of injury that may not be readily apparent. Among the important items to assess are alterations in mental status, especially compared with their initial presentation, trends in vital signs, urine output, and any worsening symptoms, including pain and respiratory difficulty.
Important and common injuries to keep in mind while performing the secondary survey include:
●Head (including intracranial) injury (see 'Head injury' below)
●Cervical spine injury (see "Suspected cervical spine injury in adults: Choice of imaging" and "Cervical spinal column injuries in adults: Evaluation and initial management" and "Spinal column injuries in adults: Types, classification, and mechanisms")
●Burns (see "Emergency care of moderate and severe thermal burns in adults")
●Clavicle and rib fractures (see "Initial evaluation and management of chest wall trauma in adults" and "Clavicle fractures" and "Inpatient management of traumatic rib fractures and flail chest in adults" and "Initial evaluation and management of rib fractures")
●Hip fracture (see "Overview of common hip fractures in adults")
●Pelvic fracture (see "Pelvic trauma: Initial evaluation and management" and "Minor pelvic fractures (pelvic fragility fractures) in the older adult")
The use of systematic management protocols (eg, checklist of examinations to perform during secondary survey) may improve outcomes for older adult trauma patients. A retrospective study reported improved survival and lower disability rates by adding age above 70 to the criteria for trauma team activation and instituting early intensive monitoring for these patients [81]. Another retrospective study reported reduced mortality after instituting a high-risk protocol for injured patients over the age of 75 based upon comorbidities, physiologic parameters, and the results of laboratory tests [65].
Analgesia — Pain control is essential to the management of injured older adults. Failure to provide analgesia is inhumane and increases the risk of delirium in this population. Nevertheless, some observational studies suggest that older trauma patients receive inadequate analgesia [82,83].
●Medications – Opioids are reasonable and may be the best option for older patients with significant pain. Fentanyl is a good choice in trauma patients because it has a rapid onset, a relatively short duration of effect, and does not cause histamine release so it is less likely to cause hypotension. Hydromorphone may also be used and has a longer duration of effect. Morphine has a harmful metabolite that is cleared by the kidneys and can cause respiratory depression and seizures if it accumulates. Sedation, urinary retention, and nausea are among the side effects of opioids. (See "Pain control in the critically ill adult patient" and "Approach to the management of acute pain in adults".)
Physiologic changes (eg, decreased kidney or liver function and altered body fat distribution) may result in higher serum drug concentrations in older adult patients given the same dose of a medication as younger individuals, so standard doses should be reduced by approximately 30 to 50 percent and then titrated to effect. Depending upon the patient's age, weight, comorbidities, and other clinical factors (eg, chronic opioid use), fentanyl doses of 25 to 100 mcg intravenously (IV) are reasonable for older trauma patients. (See 'Clinical anatomy and pathophysiology' above and 'Age-related risk factors' above.)
We prefer to avoid nonsteroidal anti-inflammatory drugs (NSAIDs) in older adult trauma patients. Such patients are likely to have some degree of compromised kidney function and are likely to be at increased risk of gastrointestinal bleeding and therefore are more susceptible to complications from NSAIDs. (See "Nonselective NSAIDs: Overview of adverse effects".)
●Nerve blocks – When the necessary resources and expertise are available, nerve blocks provide effective means for managing pain, while reducing the risk of complications from IV and oral medications (eg, respiratory depression, altered mental status). The use of regional, peripheral, and local nerve blocks is reviewed in detail separately. (See "Overview of peripheral nerve blocks" and "Upper extremity nerve blocks: Techniques" and "Lower extremity nerve blocks: Techniques".)
Injuries for which nerve blocks are well suited may include rib fractures, hip fractures, and significant injuries of the extremities. (See "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Regional anesthesia' and "Anesthesia for orthopedic trauma".)
Diagnostic testing — In general, we obtain the following laboratory studies in older adult trauma patients with known or at significant risk for major injuries:
●Blood type and crossmatch
●Blood lactate
●Arterial or venous blood gas
●Serum hemoglobin concentration and hematocrit
●Serum creatinine and blood urea nitrogen
●Serum glucose
●Basic serum electrolyte concentrations (including Na+, K+, Cl-, HCO3-)
●Prothrombin time with international normalized ratio
●Electrocardiogram (ECG)
Indiscriminate laboratory testing is rarely helpful in initial trauma management, but additional tests may be needed depending upon clinical circumstances. As an example, it is reasonable to obtain a creatine kinase to assess for rhabdomyolysis in an older patient who may have been lying on the ground for several hours following a fall.
Lactate concentrations and base deficit measurements can be helpful in the management of older adults with multisystem trauma, who are at increased risk of occult injury. For patients with signs of hypoperfusion or patients without such signs but whose initial serum lactate or blood gas results suggest hypoperfusion, we suggest obtaining repeat measurements every one to two hours. Combined with clinical parameters (eg, heart rate, urine output), serial laboratory values can help clinicians determine whether resuscitation is adequate. Rising or persistently elevated serum lactate measurements (≥2.4 mmol/L) strongly suggest ongoing hypoperfusion. (See "Initial management of trauma in adults", section on 'Laboratory tests'.)
Both lactate and base deficit are sensitive markers of hypoperfusion, even in situations where the older adult patient is "normotensive" [84]. In addition, both may help clinicians to gauge the patient's response to initial resuscitation efforts, and determine appropriate disposition (ie, whether intensive care unit admission is necessary) and mortality risk [85]. According to one review, a base deficit greater than -6 on the admission arterial blood gas is associated with a 60 percent mortality rate in trauma patients 55 years and older [8].
Imaging studies — Given the increased risk of severe occult injury and less concern about the effects of radiation exposure, it is reasonable to use a lower threshold for performing extensive imaging studies of older trauma patients [86,87]. Older patients at risk for significant internal injury and whom it is difficult (eg, dementia, head injury) or impossible (eg, intubated) to assess adequately should be imaged liberally if possible and consistent with the goals of care. When performing computed tomography (CT) imaging in this population, contrast nephropathy is a concern and all suitable steps to prevent this complication should be taken. However, clinicians should not forego CT imaging out of concern for contrast nephropathy. (See "Prevention of contrast-associated acute kidney injury related to angiography" and "Contrast-associated and contrast-induced acute kidney injury: Clinical features, diagnosis, and management".)
COMMON AND HIGH-RISK INJURIES
Head injury — Older age is an independent risk factor for morbidity and mortality in patients with head trauma, both major and minor [23,88,89]. According to large retrospective studies, older adult patients with severe traumatic brain injury (defined as a sustained Glasgow Coma Scale [GCS] <9 (table 7)) have at least an 80 percent likelihood of death or major disability leading to placement in a long-term care facility [90]. Most head trauma in older adult patients occurs from falls. Early diagnosis and intervention is critical to reducing the dangers associated with intracranial hemorrhage. (See "Management of acute moderate and severe traumatic brain injury".)
Of note, the GCS may be less accurate in older adults. Given the physiologic changes in this population, significant intracranial injury may be present even in the setting of a normal or relatively high GCS score [91,92]. (See "Stupor and coma in adults", section on 'Glasgow Coma Scale'.)
Whom to image — In nearly all cases of head trauma in older adults, it is prudent to obtain a CT scan of the head. In addition to the increased risk of injury in this population, the neurologic examination can be unreliable for detecting signs of significant intracranial hemorrhage [80,89,93]. Observational studies strongly suggest that patients with a minor mechanism of injury and no abnormalities on neurologic examination may still have significant subdural or epidural bleeding.
Although several well-validated clinical practice guidelines may be used to reduce the number of CT scans performed on younger patients with head trauma (eg, New Orleans Criteria, National Emergency X-Radiography Utilization Study II [NEXUS II], and the Canadian CT Head Rule), they cannot be used for older patients, as older age is an explicit criteria for obtaining imaging (>60 years in the New Orleans Criteria, >65 years in the Canadian rule and NEXUS II). (See "Acute mild traumatic brain injury (concussion) in adults", section on 'Imaging'.)
Patients taking anticoagulants
Risk of bleeding — Nearly 10 percent of older adult patients presenting with head trauma are taking warfarin, while a significant percentage take other anticoagulants or antiplatelet agents [94]. The rate of intracranial hemorrhage in asymptomatic head injury patients on warfarin approaches 15 percent in some studies [95]. Intracranial hemorrhage can occur following minimal trauma [96]. Even therapeutic anticoagulation is associated with adverse outcomes in the older adult with a head injury, according to retrospective data [97]. Reversal of anticoagulation should be performed as soon as the need is recognized, as the rate and volume of bleeding are among the most important determinants of morbidity and mortality from intracranial hemorrhage [98].
The risk of delayed intracranial hemorrhage is low, even among those on anticoagulant therapy, according to evidence from several large, prospective and retrospective observational studies of older adults with acute head trauma [99-101].
Treatment of life-threatening bleeding — We concur with management guidelines from the Eastern Association for the Surgery of Trauma, which suggest that all older adult patients taking warfarin who have evidence of a post-traumatic intracranial hemorrhage (ICH) on CT have their international normalized ratio (INR) corrected toward a normal range (eg, <1.6 x normal) within two hours of admission [85]. We suggest the same approach be taken with older trauma patients taking warfarin who manifest any decline in mental status or develop a neurologic deficit, or who have a supratherapeutic INR and sustained head trauma of any kind [80,102]. Some older adult trauma patients may be taking anticoagulants other than warfarin. In resource-limited settings, reversal of anticoagulation may be necessary without confirming the presence of intracranial hemorrhage by CT.
Reversal of anticoagulation in patients with ICH is reviewed in detail separately; initial emergency interventions are summarized in the tables below. (See "Reversal of anticoagulation in intracranial hemorrhage".)
●Initial emergency treatment to reverse anticoagulation due to warfarin in patients with life-threatening hemorrhage is summarized in the following table (table 8).
●Initial emergency treatment to reverse anticoagulation from direct oral anticoagulants (eg, dabigatran) is summarized in the following table (table 9).
Several treatments may be used to reverse anticoagulation, including prothrombin precipitate complex, fresh frozen plasma (FFP), vitamin K, cryoprecipitate, and possibly recombinant human factor VIIa. Non-crossmatched FFP may be given initially to reduce the time required for reversal (initial dose 2 units intravenously [IV] by rapid infusion) [102]. FFP should be administered using the smallest volumes possible to minimize the risk of fluid overload.
For the treatment of potentially life-threatening bleeding associated with warfarin, 4-factor prothrombin complex concentrate is the preferred treatment. In addition, warfarin should be stopped and 10 mg of vitamin K given by slow IV infusion (eg, over 20 minutes).
Observation in patients without bleeding initially — Largely due to the limited evidence available, debate continues about the need for observation of patients on warfarin who sustain a closed head injury but whose initial CT scan shows no acute ICH. Although not written specifically for older adult patients, we agree with the basic approach outlined in the American College of Emergency Physician guidelines for mild traumatic brain injury [103]. While anticoagulant and antiplatelet medications are associated with a higher risk of ICH after mild head trauma, initial neuroimaging is generally sufficient to exclude clinically significant ICH in patients who appear neurologically intact at baseline. Therefore, we agree it is reasonable to discharge stable patients with a negative CT scan, provided they have no other significant injuries and a stable environment to which to return (including someone responsible to bring them to medical care should concerning symptoms develop).
Evidence to determine the optimal approach is scant, but includes the following:
●A prospective observational study of 97 consecutive patients who sustained minor head trauma while on warfarin used a protocol of 24-hour observation followed by a second CT scan reported a 6 percent rate of delayed bleeding and identified all but two patients with such bleeding [104]. These two patients were admitted two and eight days later with symptomatic subdural hematomas but neither required surgical intervention.
●Another prospective observational study assessed immediate and delayed bleeding in 1064 patients who sustained blunt head trauma while on anticoagulants and found a higher prevalence of immediate hemorrhage in patients receiving clopidogrel (33 out of 276, 12 percent) compared with warfarin (37 out of 724, 5.1 percent) (relative risk 2.31; 95% CI 1.48-3.63) [105]. The study found few delayed bleeds in either group (4 out of 687 warfarin patients; 0 out of 243 clopidogrel patients).
Severe extracranial hemorrhage and anticoagulation reversal — The general management of severe extracranial hemorrhage is unchanged in older adult trauma patients (algorithm 1). Pre-existing conditions such as ischemic heart disease, heart failure, or kidney dysfunction can cause older adult patients to decompensate from excessive fluid administration or blood loss. Therefore, it is reasonable to begin transfusing blood products early if hypotension or signs of hypoperfusion exist. (See 'Circulation' above and "Initial management of moderate to severe hemorrhage in the adult trauma patient".)
Reversal of anticoagulation in patients with ICH is reviewed above and discussed in greater detail separately. (See 'Treatment of life-threatening bleeding' above and "Reversal of anticoagulation in intracranial hemorrhage".)
Methods for the reversal of anticoagulation in patients with severe extracranial hemorrhage are summarized in the following tables (table 8 and table 9) and reviewed in detail separately:
●Warfarin (see "Management of warfarin-associated bleeding or supratherapeutic INR", section on 'Serious/life-threatening bleeding')
●Heparin (see "Heparin and LMW heparin: Dosing and adverse effects", section on 'Reversal')
●Low molecular weight heparin (see "Heparin and LMW heparin: Dosing and adverse effects", section on 'Reversal')
●Direct thrombin inhibitors (eg, dabigatran) and factor Xa inhibitors (eg, rivaroxaban, apixaban, edoxaban) (see "Management of bleeding in patients receiving direct oral anticoagulants", section on 'Anticoagulant reversal')
Cervical spine injury — The major clinical decision rules used to assess cervical spine injury, including the National Emergency X-Radiography Utilization Study [106] and the Canadian Cervical Spine Rule [107], are less sensitive in excluding cervical spine fractures in older adult patients (>65 years). This is because the incidence of cervical spine injury is greater in older adults, and evaluation is more difficult (history and examination may be less sensitive for injury) [108-111]. The effectiveness and application of these decision rules to trauma patients, including older adults, are discussed separately. (See "Cervical spinal column injuries in adults: Evaluation and initial management", section on 'Clinical decision rules'.)
Older adult patients can sustain cervical fractures from seemingly minor mechanisms, such as a fall from a standing position [26,111,112]. In a systematic review of studies that included adults ≥65 years old who sustained low-level falls (eg, fall from sitting, level ground, or no more than two steps; 21 studies, 17,192 patients), researchers found that approximately 4 percent suffered a cervical spine fracture, dislocation, or ligamentous injury [111].
In particular, high cervical fractures (eg, odontoid) are significantly more common [108]. Type II odontoid fractures are among the most common cervical spine fractures in older adults (image 1) [31]. Conditions such as cervical stenosis and degenerative rheumatoid and osteoarthritis, which are also more common in older patients, make the spine more vulnerable to fracture and the interpretation of plain radiographs more difficult. In addition, both the history and physical examination may be less sensitive for detecting injury in older adult patients [109,110]. Therefore, liberal use of advanced imaging studies (eg, CT) is warranted for those at risk for spinal injury.
Central cord syndrome is a complication of cervical spine injury that occurs more often in older trauma patients (figure 1 and table 10). It is most frequently the result of a hyperextension injury in individuals with long-standing cervical spondylosis and is characterized by disproportionately greater motor impairment in upper compared with lower extremities, bladder dysfunction, and a variable degree of sensory loss below the level of injury. (See "Anatomy and localization of spinal cord disorders", section on 'Central cord syndromes'.)
Chest trauma — Rib fractures are the most common chest injury sustained by older adult patients and are associated with an increased risk of complications and death [32,113-116]. Given these risks, admission and close observation is generally indicated for older patients with even one rib fracture, and advanced imaging is warranted in older patients with multiple rib fractures (image 2 and image 3). Many older patients, especially those with three or more rib fractures or any sign of respiratory difficulty, are admitted to an intensive care setting. Disposition of patients with rib fractures is reviewed in greater detail separately. (See "Initial evaluation and management of rib fractures", section on 'Disposition'.)
The initial management of chest wall trauma and thoracic injury are discussed separately. (See "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of chest wall trauma in adults" and "Initial evaluation and management of rib fractures".)
Systematic reviews of studies of risk factors for death following blunt chest wall trauma confirm that older adults are at significant risk of complications (eg, pneumonia, pulmonary contusion) and mortality with even three or fewer nondisplaced rib fractures [114,117]. Major risk factors for mortality following blunt chest wall trauma include age 65 years or older, three or more rib fractures, and pre-existing cardiopulmonary disease. In a retrospective cohort study, mortality increased by approximately 19 percent for each rib fracture in patients over the age of 65 [32]. A subsequent study found a 30-day mortality rate of 11.7 percent in patients 65 or older with one or more rib fractures [118].
Another systematic review of data from the United States National Trauma Data Bank that included several hundred thousand patients with rib fractures found that control of pain with neuraxial blockade and intensive care unit admission were associated with reduced mortality among patients older than 65 years with three or more rib fractures, but that eligible patients often did not receive these interventions [119].
Abdominal trauma — Although abdominal injury patterns are similar in older and younger adult trauma patients, diminished pain sensation and increased laxity of abdominal wall musculature make the abdominal examination less reliable in older adults. Therefore, early evaluation (with reassessment as indicated) to detect intraperitoneal hemorrhage (most often using ultrasound) is important. (See "Emergency ultrasound in adults with abdominal and thoracic trauma" and "Blunt abdominal trauma in adults: Initial evaluation and management".)
In stable patients, it is best to obtain a CT scan if intra-abdominal injury is suspected. The risk of contrast-induced nephropathy (CIN) is higher in older adult patients, particularly in the presence of hypovolemia, chronic kidney disease, or diabetes, and measures should be taken to avoid this complication. However, clinicians should not forego CT imaging out of concern for CIN. The long-term consequences of CIN remain unclear and pale beside the consequences of missing any severe internal injury in an older adult. (See "Blunt abdominal trauma in adults: Initial evaluation and management" and "Prevention of contrast-associated acute kidney injury related to angiography" and "Contrast-associated and contrast-induced acute kidney injury: Clinical features, diagnosis, and management".)
It is best to obtain early surgical consultation for known or suspected intra-abdominal injury because such injuries can be difficult to assess in older patients and because operative management of solid organ injuries (eg, splenic injury) may be preferable to nonoperative management [120]. Strategies for reversing anticoagulation in older adults with significant bleeding are discussed above. (See 'Treatment of life-threatening bleeding' above.)
Musculoskeletal injuries of the pelvis, hip, and extremities — Musculoskeletal injuries are the most common type of injury sustained by geriatric trauma patients. Many of these injuries are associated with increased mortality in this population [5]. Hip fractures are the most common injury requiring hospital admission [24]. Plain radiographs are often sufficient to identify hip fractures, but magnetic resonance imaging (MRI) may be needed to assess occult fracture. (See "Overview of common hip fractures in adults".)
Pelvic fracture patterns among older adult patients with major trauma are similar to younger adults, although lateral compression fractures may be more common [121]. Following minor trauma, older adult patients may sustain fractures of the pubic rami or sacral ala, as well as hip fractures and other more common injuries. (See "Pelvic trauma: Initial evaluation and management" and "Minor pelvic fractures (pelvic fragility fractures) in the older adult".)
Regardless of type, pelvic fractures in older adults are associated with significantly greater morbidity, including major hemorrhage, and mortality [39,122,123]. One review of geriatric trauma reported a mortality rate of up to 30 percent in older adult patients from acute or delayed complications of pelvic fractures [124]. A retrospective study of 234 older adult patients with pelvic fractures found that patients over the age of 55 were four times more likely to die from complications of their pelvic fracture than younger patients [122]. The authors suggest that every older adult patient with a pelvic fracture be considered hemodynamically unstable until proven otherwise. Strategies for reversing anticoagulation in older adults with significant bleeding are discussed above. Pelvic fragility fractures are typically not associated with significant bleeding. (See 'Treatment of life-threatening bleeding' above and "Minor pelvic fractures (pelvic fragility fractures) in the older adult".)
Given the increased risks associated with pelvic fractures in this population, we suggest taking an aggressive approach to identifying and stopping bleeding. The approach will vary by institution, but early surgical consultation and investigation (eg, angiography, CT-angiography) is warranted in any older adult patient with a pelvic fracture, other than a minor fracture of a pubic ramus, and evidence of hemorrhage (eg, elevated heart rate, ongoing transfusion requirements, pelvic hematoma on standard CT) [39].
In addition to hip and pelvis fractures, other common injury sites include the distal radius and ulna, proximal humerus, and clavicle [125]. As many of these extremity injuries are associated with increased mortality, clinicians should look carefully for such fractures when evaluating geriatric trauma patients [5].
Skin wounds — Older adult trauma victims are more likely to sustain skin tears and other superficial wounds. Although these injuries often require longer to heal than comparable wounds in younger patients, management is essentially the same. (See "Principles of acute wound management" and "Clinical assessment of chronic wounds" and "Minor wound evaluation and preparation for closure".)
DISPOSITION —
Disposition of the geriatric trauma patient depends upon their underlying health and the injuries sustained or suspected. Admission or transfer to a trauma center is appropriate for patients over the age of 65 with any of the following:
●Injury from blunt chest trauma (even a single rib or clavicle fracture)
●Blunt abdominal trauma associated with any symptoms or findings
●Head trauma with any alteration in mental status or other sign of injury (eg, hemotympanum, retroauricular ecchymosis)
●Extremity trauma that limits the patient's ability to perform activities of daily living
●Concerning symptoms such as pain that is not easily controlled or shortness of breath
Transfer to a trauma center should not be delayed to complete imaging studies. Special care should be taken with older patients who have significant underlying comorbidities such as cardiopulmonary disease, as such conditions dramatically increase the risk for adverse outcomes following trauma. (See 'Age-related risk factors' above.)
In addition to the general guidelines above, we suggest admission to an intensive care setting in a trauma center whenever possible for older adult patients with significant injury to one or more organ systems, two or more rib fractures, a serum lactate concentration ≥2.4 mmol/L, or concerning vital sign trends (eg, increasing heart or respiratory rate), even if the absolute measurements are not grossly abnormal.
Potential causes of trauma in older adults include cardiac syncope, myocardial infarction, infection, and stroke. Therefore, determining the cause of trauma is another potential reason for admitting the older adult patient to the hospital. Older age is not an absolute predictor of poor outcome following trauma and should not be used as the sole criterion for denying or limiting care [85]. The Geriatric Trauma Outcome Score (GTOS) is a useful tool for assessing in-hospital mortality risk in the injured older adult patient [126-128]. The GTOS includes three variables:
●Patient age
●Injury Severity Score
●Blood transfusion within 24 hours of admission (22 points if performed)
Older adults found to have only minor injuries from trauma, no concerning underlying medical cause, and appropriate social supports and medical follow-up may be discharged. The importance of follow-up cannot be overemphasized. Among older adults who are discharged appropriately from the emergency department following minor injury, a substantial number experience functional decline following the incident. As an example, in a prospective, multicenter study of nearly 3000 adults over the age of 65 discharged home following minor trauma, 17 percent (95% CI 12.5-23 percent) experienced a significant functional decline over the subsequent six months [129]. Thus, it is important to ensure that appropriate follow-up is arranged. This may include assessments by primary care, physical therapy, visiting nursing, and social services. (See "Comprehensive geriatric assessment".)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General issues of trauma management in adults".)
SUMMARY AND RECOMMENDATIONS
●Definitions and epidemiology – There is no clear definition of geriatric trauma; we consider patients 65 and older to be older adults (ie, geriatric). Older adults have greater morbidity and mortality for virtually all traumatic injuries and mechanisms. Even apparently benign mechanisms (eg, fall from standing) can cause significant injury. With proper care and appreciation for the differences in injured older adults, a return to baseline functional status is a reasonable expectation for many patients, including those with major injuries. (See 'Definition' above and 'Epidemiology and mechanisms of injury' above.)
●Anatomy and physiology – Multiple anatomic and physiologic changes that accompany aging place the geriatric trauma patient at greater risk of injury and death, and impair their capacity to respond to the stress of injury (table 1 and table 2). Frailty is associated with worse outcomes (table 3). (See 'Clinical anatomy and pathophysiology' above and 'Age-related risk factors' above.)
In addition, older patients frequently have pre-existing conditions that diminish physiologic reserve and take medications that mask signs of injury. Clinicians must remain vigilant, even in the setting of "normal" vital signs and "minor" mechanisms.
●Under-triage – Under-triage is a significant problem in older adults, increasing their risk for morbidity and death. We suggest that trauma patients over the age of 70 be evaluated at a trauma center with trauma team activation whenever possible, regardless of the mechanism. In addition, we suggest that any patient 65 or older with a systolic blood pressure <110 mmHg be transported directly to a trauma center for evaluation, and that a heart rate of 90 be used as the threshold for tachycardia in patients in this age group. (See 'Problem of under-triage' above.)
●History – In addition to the standard trauma history, the following questions are important to address with geriatric trauma:
•Events just prior to trauma – What happened immediately before the trauma (eg, altered consciousness, difficulty breathing, change in vision)?
•Medications – What medications is the patient taking (eg, anticoagulant, antiplatelet, beta blocker, calcium channel blocker)?
•Comorbidity – What underlying illnesses does the patient have (eg, hypertension, cardiovascular or kidney disease, diabetes)?
•Baseline function – What was the patient's baseline level of motor and cognitive function prior to the traumatic event?
•Advanced directives – Does the patient have a written advanced directive or a health care proxy that may be useful for determining the goals of care?
●Airway and breathing – Blunted responses to hypoxia, hypercarbia, and acidosis can delay clinical signs of distress in older adult trauma patients. Serious injuries may be present even when concerning clinical findings are not apparent initially. Diminished respiratory reserve often prevents patients from compensating adequately for chest injuries. Early aggressive airway management may be necessary and may include tracheal intubation or noninvasive positive pressure ventilation. (See 'Overview' above and 'Airway and breathing' above.)
●Circulation – "Normal" vital signs in geriatric trauma patients may be substantially different from their younger counterparts; recognizing early shock is more difficult. Baseline hypertension is common and can cause relative hypotension to be misinterpreted as a blood pressure in the "normal" range. The effect of medications (eg, beta blocker) can obscure the meaning of vital sign measurements. Trends of vital signs are often more useful than any individual measurement. (See 'Circulation' above.)
Aggressive resuscitation is appropriate for the initial treatment of older adult trauma patients with hypotension or signs of hypoperfusion. However, pre-existing conditions such as ischemic heart disease, heart failure, or chronic kidney dysfunction can cause older adults to decompensate from excessive fluid administration or blood loss. Therefore, it is reasonable to begin transfusing packed red blood cells if hypotension or signs of hypoperfusion are present. (See 'Circulation' above.)
●Monitoring – As older trauma patients may not manifest obvious signs of injury, close monitoring is essential. Monitoring should include serial examinations, including vital signs, mental status, and reassessment of any areas of concern. In addition to a cardiac monitor and pulse oximeter, we suggest using an end-tidal CO2 monitor for any older patient with the potential for respiratory problems. (See 'Monitoring' above.)
●Diagnostic testing – We obtain basic laboratory studies in older adult trauma patients with known or at significant risk for major injuries. These studies are listed in the text. Lactate concentrations and base deficit measurements can be helpful in the management of older adults with multisystem trauma, who are at increased risk of occult injury. (See 'Diagnostic testing' above.)
●Secondary survey – A thorough systematic secondary survey is necessary for all older adult trauma patients. Important and common injuries to keep in mind include: head (eg, intracranial) injury, cervical spine injury, major burns, clavicle and rib fractures, hip fracture, and pelvic fracture. A checklist to assist with this evaluation is provided (table 6). (See 'Common and high-risk injuries' above and "Secondary survey (evaluation) of the adult trauma patient".)
●Intracranial hemorrhage and cervical spine injury – Older age is an independent risk factor for morbidity and mortality from head trauma. Thus, in nearly all cases of head trauma in older adults, it is prudent to obtain a CT scan of the head and neck. The management of patients taking anticoagulants is described in the text. High cervical fractures (eg, odontoid) are more common in older adult patients. (See 'Head injury' above and 'Cervical spine injury' above.)
●Abdominal trauma – Diminished pain sensation and increased laxity of abdominal wall musculature make the abdominal examination less reliable in older adults. Early evaluation to detect intraperitoneal hemorrhage (eg, using ultrasound) is important. In stable patients, it is best to obtain a CT scan if intra-abdominal injury is suspected. (See 'Abdominal trauma' above.)
