Trauma in elderly and frail patients — WSES 2023

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]

First-line treatment

Interventions

Trauma triage with low threshold for trauma centre transfer
Use an early, low threshold for trauma protocol activation in older patients, assessing mechanism, injury severity, frailty, comorbidities and medication history. WSES suggests early activation from age 55 and gives geriatric triage set points of heart rate 90 bpm and systolic BP<110 mmHg; apply these with clinical assessment. [2]
Damage-control resuscitation tailored to elderly
Individualize resuscitation using perfusion, serial lactate/base deficit, urine output, mental status, pre-existing disease and medicines. Minimize excess fluids and carefully assess permissive hypotension in selected older patients. The guideline does not establish a single transfusion threshold for all elderly trauma patients. [2]
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
Use multimodal analgesia with regular IV acetaminophen every 6 hours, regional/peripheral blocks and cautious opioid use. Consider NSAIDs only after weighing adverse effects and interactions. Assess bleeding risk carefully before neuraxial or plexus blocks in anticoagulated patients. [2]
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

First-line drug therapy

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)	Anti-dabigatran monoclonal antibody fragment	The WSES guideline gives idarucizumab 5 g IV for qualifying dabigatran-associated uncontrolled life-threatening bleeding. Product administration details and any repeat dose need a current prescribing source. [2]	—	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)	Recombinant factor Xa decoy	Low-dose 400 mg IV bolus + 4 mg/min × 120 min; high-dose 800 mg + 8 mg/min × 120 min	—	The WSES2024 paper describes historical andexanet use for qualifying uncontrolled life-threatening apixaban/rivaroxaban bleeding. FDA’s December18,2025 safety communication subsequently concluded that Andexxa’s risks outweigh its benefits; FDA announced that AstraZeneca would stop manufacture for, and sales in, the US after December22,2025. Do not present this historical WSES entry as an unqualified current prescribing recommendation. Indian regulatory status and availability require separate verification. [2][3]
Paracetamol + regional anaesthesia (analgesia backbone)	Multimodal analgesia	WSES recommends regular IV acetaminophen every 6 hours within multimodal analgesia and skilled regional/peripheral blocks when appropriate. It does not establish an unqualified 1 g oral/IV dose for every elderly trauma patient; select dose using current prescribing information and patient factors. [2]	—	Reduces opioid requirement, delirium, and pulmonary complications; involve anaesthetic and pain teams early

Tranexamic acid (early haemorrhage)^[1]

Antifibrinolytic

Adult: 1 g IV over 10 min within 3 h of injury, then 1 g IV over 8 h
Paediatric: —

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

Adult: 25–50 IU/kg IV (weight + INR-adjusted) + IV vitamin K 5–10 mg
Paediatric: 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)

Anti-dabigatran monoclonal antibody fragment

Adult: The WSES guideline gives idarucizumab 5 g IV for qualifying dabigatran-associated uncontrolled life-threatening bleeding. Product administration details and any repeat dose need a current prescribing source. [2]
Paediatric: —

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)

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: —

The WSES2024 paper describes historical andexanet use for qualifying uncontrolled life-threatening apixaban/rivaroxaban bleeding. FDA’s December18,2025 safety communication subsequently concluded that Andexxa’s risks outweigh its benefits; FDA announced that AstraZeneca would stop manufacture for, and sales in, the US after December22,2025. Do not present this historical WSES entry as an unqualified current prescribing recommendation. Indian regulatory status and availability require separate verification. [2][3]

Paracetamol + regional anaesthesia (analgesia backbone)

Multimodal analgesia

Adult: WSES recommends regular IV acetaminophen every 6 hours within multimodal analgesia and skilled regional/peripheral blocks when appropriate. It does not establish an unqualified 1 g oral/IV dose for every elderly trauma patient; select dose using current prescribing information and patient factors. [2]
Paediatric: —

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

Safety-net

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]

Referral criteria

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]

Clinical summary

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

References

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)
2.The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World Journal of Emergency Surgery (2024)
3.Update on the Safety of Andexxa: FDA Safety Communication, December 18, 2025. FDA (2025)