Trauma in elderly and frail patients

Red Flags

Major mechanism (high-energy fall, RTC) or any mechanism with anticoagulation — trauma centre transfer with low threshold; CT head and trunk^[1]
Hip fracture in elderly — surgery within 24–48 h reduces mortality; early mobilisation; orthogeriatric service^[1]
Anticoagulation-related intracranial haemorrhage — emergency reversal (PCC for warfarin; idarucizumab for dabigatran; andexanet alfa for apixaban/rivaroxaban); neurosurgery^[1]
Multiple rib fractures or flail segment — analgesia (regional anaesthesia preferred), respiratory monitoring, early mobilisation; ICU if pulmonary contusion or impaired gas exchange^[1]

Trauma triage with low threshold for trauma centre transfer^[1]
Older adults under-triaged in standard scoring; activate trauma team for any moderate mechanism, anticoagulation, or physiological compromise; avoid 'mild trauma' label
Damage-control resuscitation tailored to elderly^[1]
Permissive hypotension less safe in elderly with chronic hypertension; lower transfusion threshold for symptomatic anaemia or cardiac comorbidity; avoid over-transfusion of crystalloid (TACO)
Early surgical fixation of fragility fractures^[1]
Hip fracture <24–48 h reduces mortality and pneumonia; orthogeriatric co-management; thromboprophylaxis; early mobilisation; bone health workup post-recovery
Multimodal analgesia minimising opioids^[1]
Regional anaesthesia (fascia iliaca, paravertebral block) for hip and rib fractures; paracetamol; topical NSAIDs cautiously; minimise sedating agents to reduce delirium and falls
Delirium prevention and management^[1]
Identify hyperactive and hypoactive delirium; address reversible causes (pain, infection, dehydration, medication); non-pharmacological measures first; antipsychotics only for safety

Drug	Class	Adult	Paediatric	Notes
Tranexamic acid (early haemorrhage)^[1]	Antifibrinolytic	1 g IV over 10 min within 3 h of injury, then 1 g IV over 8 h	—	CRASH-2 protocol; no upper age limit; avoid if known thromboembolic event in last 12 months; reduces mortality in bleeding trauma
Prothrombin complex concentrate (PCC) for warfarin reversal^[1]	Vitamin K-dependent factor concentrate	25–50 IU/kg IV (weight + INR-adjusted) + IV vitamin K 5–10 mg	25–50 IU/kg IV	First-line for warfarin-related major bleeding; faster than FFP; avoid in HIT history; check INR 30 min post-dose
Idarucizumab (dabigatran reversal)^[1]	Anti-dabigatran monoclonal antibody fragment	5 g IV (2 × 2.5 g) over 5–10 min	—	Specific reversal for dabigatran-related bleeding or emergency surgery; can re-dose if bleeding recurs and dabigatran level still measurable
Andexanet alfa (apixaban/rivaroxaban reversal)^[1]	Recombinant factor Xa decoy	Low-dose 400 mg IV bolus + 4 mg/min × 120 min; high-dose 800 mg + 8 mg/min × 120 min	—	Specific reversal for apixaban/rivaroxaban major bleeding; high cost; PCC alternative where unavailable; risk of thrombosis post-reversal
Paracetamol + regional anaesthesia (analgesia backbone)^[1]	Multimodal analgesia	Paracetamol 1 g PO/IV QDS; fascia iliaca block for hip fracture; paravertebral or erector spinae for rib fractures	—	Reduces opioid requirement, delirium, and pulmonary complications; involve anaesthetic and pain teams early

Tranexamic acid (early haemorrhage)^[1]

Antifibrinolytic

CRASH-2 protocol; no upper age limit; avoid if known thromboembolic event in last 12 months; reduces mortality in bleeding trauma

Prothrombin complex concentrate (PCC) for warfarin reversal^[1]

Vitamin K-dependent factor concentrate

First-line for warfarin-related major bleeding; faster than FFP; avoid in HIT history; check INR 30 min post-dose

Idarucizumab (dabigatran reversal)^[1]

Anti-dabigatran monoclonal antibody fragment

Specific reversal for dabigatran-related bleeding or emergency surgery; can re-dose if bleeding recurs and dabigatran level still measurable

Andexanet alfa (apixaban/rivaroxaban reversal)^[1]

Recombinant factor Xa decoy

Adult: Low-dose 400 mg IV bolus + 4 mg/min × 120 min; high-dose 800 mg + 8 mg/min × 120 min
Paediatric: —

Specific reversal for apixaban/rivaroxaban major bleeding; high cost; PCC alternative where unavailable; risk of thrombosis post-reversal

Paracetamol + regional anaesthesia (analgesia backbone)^[1]

Multimodal analgesia

Adult: Paracetamol 1 g PO/IV QDS; fascia iliaca block for hip fracture; paravertebral or erector spinae for rib fractures
Paediatric: —

Reduces opioid requirement, delirium, and pulmonary complications; involve anaesthetic and pain teams early

Falls in older adults rarely reflect a single cause — assess medications, vision, balance, cognition, home environment after recovery^[1]
On anticoagulation: any head injury, even minor, warrants observation and CT; report changes in alertness, severe headache, vomiting^[1]
Mobilise as soon as safely possible after fracture surgery — bed rest worsens outcomes; physiotherapy and OT involvement essential^[1]

Major mechanism, polytrauma, or anticoagulation-related injuryMajor trauma centre^[1]
Hip fractureOrthogeriatric service for surgery within 24–48 h and rehabilitation^[1]
Frailty plus repeated falls or significant traumaMultidisciplinary falls clinic / geriatric assessment^[1]
Persistent delirium, functional decline, or carer breakdown post-injuryGeriatric and rehabilitation services^[1]

Triage, anticoagulation reversal, frailty-adjusted management, and rehabilitation of injured older adults.

1.WSES Guidelines on the Management of Trauma in Elderly and Frail Patients (2023); ACS-COT Best Practices in the Care of the Geriatric Trauma Patient (2023)