An older person falling from standing is now the commonest type of major trauma.

Older people's trauma screening tool for TUs, MTCs, and Local Emergency Hospitals.

Inclusion criteria: “All patients ≥ 65 who self-present or arrive by ambulance with an obvious injury, mechanism of injury, or who have fallen < 2m.”

Red criteria → immediate EM consultant or registrar (ST4+ or equivalent) review, and a trauma call (document if the decision is not to activate)

Anatomy of injury: significant injury to ≥ 2 body regions; suspected pelvic injury; suspected head or spinal injury; suspected chest injury.

Physiology: systolic BP < 110 mmHg; heart rate > 90 bpm; GCS < 15 (even if baseline); lactate > 2 or base excess < −2.

Other: patient on anticoagulant medication or has a bleeding disorder; severe pain; acutely short of breath; uncontrollable major haemorrhage.

Amber criteria → EM consultant or registrar (ST4+ or equivalent) review within 15 minutes; repeat screen post examination / imaging

History of unconsciousness; significant medical history, co-morbidities; inappropriate or inadequate history; inappropriate awareness of symptoms / injury.

And the rule that catches the late presentation

“In the absence of mechanism – but identification of injury on any imaging then re-screen patient.”

The stated purpose of the trauma call, and of the patient's clinical priority, is “adequate examination, early and adequate imaging and reporting, and early identification of all injuries”.

The tool is “adapted from HECTOR elderly trauma triage criteria and pre-hospital tools (by D Peel, A Osmond, H Tucker 2018)”. The red criteria “are independently and significantly associated with the identification of trauma in a retrospective multivariate analysis”.

TARN's 2017 report reviewed 8,176 patients aged 60 and over with an Injury Severity Score greater than 15, admitted during 2014. Its central finding: “an older person suffering a fall from standing height is now the commonest type of major trauma in the national database”, and this age group “now accounts for more than 50% of the severely injured patients registered in the Trauma Audit and Research Network database”.

The report describes a cascade rather than a single failure:

“Shortcomings in the early identification of major trauma in older people leads to a low rate of positive prehospital triage with low rates of bypass to a Major Trauma Centre (MTC); low levels of pre-alert; low levels of trauma team activation and initial management by relatively junior doctors. This lower level of early activation of the trauma care system seems to lead to delays in both investigation and management.”

On seniority, the numbers are stark. The proportion of older patients initially treated by a consultant “was near to 100% if they were positive on the prehospital trauma triage tool, whatever the time of injury”. Where pre-hospital triage was negative or not done, “approximately 40% of these patients saw a consultant if they were admitted during the day, and this was further reduced to about 30% during the night.”

And the honest statement of the problem — the reason a screening tool has to be this wide:

“There is therefore a ‘needle in a haystack’ problem for the trauma system… Given the prevalence of low falls in older people, it would not be possible to activate the major trauma protocol for all of these incidents. However, current trauma triage protocols (which were primarily designed for much younger patient populations) are not working well for older people and do not reliably distinguish older patients with low falls who have sustained serious injuries from those who have not.”

One further group is easy to forget: 3.2% of older major trauma patients were “either admitted directly to a medical ward (1.7%) or sustain their injuries by falling while in hospital (1.3%)”. TARN notes these patients “may eventually be found to have a significant head or chest injury that was not immediately apparent on initial assessment”.

TARN used age 60 as its cut-off because “in the trauma data there seems to be a change in the age / outcome relationship at about 60 years old”. The LMTS guideline uses 65. Neither number is a biological threshold.

From the LMTS key principles: “Ageing, comorbid disease, medications and frailty may all affect the expected physiological presentation of major trauma in older people.” And: “Older trauma patients may not present with an obviously significant mechanism.”

The pelvic injury section states the mechanism plainly: “Hypovolaemic shock may be difficult to detect in older people due to pre-existing hypertension, altered cardiovascular reserve or beta-blocker therapy. Early assessment of lactate or base deficit (excess) and haemoglobin on arrival to the ED may help to detect haemodynamic compromise following pelvic trauma, irrespective of mechanism of injury.”

This is why the screening tool's thresholds sit where they do. A systolic of 115 in a patient whose usual pressure is 170 is not a normal blood pressure, and a rate-controlled heart cannot mount a tachycardia. The tool responds by moving the trigger points — systolic < 110 and heart rate > 90 — and by adding a metabolic criterion, lactate > 2 or base excess < −2, that does not depend on the patient's ability to compensate.

GCS < 15 “even if baseline” deserves separate attention. The parenthesis exists because “this is their normal” is the most common way a reduced conscious level gets written off in this group.

“There should be a low threshold for initiating a ‘trauma call’ and obtaining a head CT scan in the older patient, especially in the following presentations:

• When known or suspected to have sustained head injury.
• Following a low level fall (e.g. from standing or sitting).
• When taking prescribed anticoagulant medication.
• When there is no clear medical cause of fall or unclear reason for ED attendance.”

The reason for that last one is given explicitly: “These suggestions are in light of the perceived number of older patients who present as a ‘collapse’ and who, after admission, are found to have an acute or chronic subdural haematoma.”

Scan the neck with the head

“Where an older patient has clear external signs of head injury or has neck pain or has endured a fall, and if a decision has been made to CT the patient's head, this should include the cervical spine.”

Blood on the CT re-opens the whole assessment

“The presence of blood on CT head should trigger review of other potential traumatic injuries by experienced trauma clinician or a delayed trauma call.” Any acute intracranial blood “should result in a discussion with the MTC team… and such referrals should be logged and documented by the referrer and the advisor.”

The repeat scan

“Anticoagulated patients with a head injury and normal initial CT head may require a repeat scan. There is no clear evidence for optimum timeframe for this repeat CT, thus local policy or a senior clinician should decide based on mechanism, frailty, social support and degree of anticoagulation.” The uncertainty is in the source — it is not this tool hedging.

Three pathways for isolated TBI

1. Unsurvivable — discussion with the neurosurgeon by phone and/or remote medicine; the patient can stay at the TU. 2. No immediate neurosurgical input — stay at the TU, repeat scan at 48 hours or as the neurosurgical team specifies; if GCS falls or a new neurological sign appears, rapid discussion with a view to critical transfer to the MTC ED, “not dependent on bed status of MTC”. 3. Neurosurgical intervention required — immediate transfer to the MTC ED with a time-critical head injury pre-alert.

“Chest wall injuries are common in older patients and are associated with significantly higher morbidity and mortality than younger patients, whether they occur as part of isolated or multi-system trauma.”

“Ten per cent of older major trauma patients have rib fractures and up to 50% of fractures in this group are undetected by plain X-ray. A meta-analysis of 50,000 patients, including 15,000 people aged over 65 years indicated an odds ratio for mortality of 1.98 for those over 65 years with any rib fractures, and for all ages an odds ratio for mortality of 2.02 with 3+ rib fractures. Associated pulmonary contusion or pre-existing chronic lung disease are also significant prognostic findings.”

Hence: “Contrast CT scan is the investigation of choice to define intrathoracic and chest wall injuries early in the older trauma pathway,” because of “the poor recognition of fractures and lung contusions with X-ray and the prognostic influence of an accurate diagnosis”.

“The type and number of affected ribs is an important consideration. Vertebrosternal ribs (ribs 1-7) have greater physiological significance than vertebrocostal ribs (ribs 8-10).”

Analgesia cautions specific to older patients

• “NSAIDs should be used with extreme caution due to renal, cardiac and GI risks. They should be used for shortest duration course possible e.g. 3-5 days.”
• “Opioids should be used in lower doses. If a strong opioid is required, clinicians should have a low threshold for choosing oxycodone due to its favourable side effect profile.”

The guideline names the bind directly: “a higher proportion of older trauma patients would benefit from regional anaesthetic techniques but are more likely to have contraindications (e.g. anticoagulants) to deep regional techniques e.g. epidural or paravertebral block insertion.”

Assessment should cover pain at rest (static) and pain on deep breathing and coughing (dynamic). Incentive spirometry or vital capacity can identify patients at risk of deterioration. Severe chest wall injuries, radiological or clinical flail chest, injuries causing respiratory compromise, or pain that cannot be controlled “should be discussed early with the MTC trauma or thoracic surgeon”.

“Evidence for the benefits of pre-hospital cervical spine immobilisation in reducing secondary neurological injury in unstable injuries is poor. There are however well documented cases of worsened neurological injury in patients with poorly fitting collars or hyperextended positions. Presence of severe degenerative disease in older patients (including ankylosing spondylitis) puts them at particular risk and consideration should be given for pragmatic alternatives to hard collar stabilisation including self-extrication, careful handling and movement mitigation, with transport in a position of comfort using soft padding and tape if necessary.”

“Older patients are at high risk of pressure ulcers, pneumonia and respiratory failure, dysphagia, delirium and raised intracranial pressure with prolonged cervical immobilisation. Many find hard collars and lying flat uncomfortable, painful and frightening.”

The clock the guideline sets: “Assessment, imaging and imaging reporting should be completed within two hours of arrival/decision to immobilize. If continued immobilization is required rigid extrication collars should be switched to soft padded collars (such as Miami-J) at the earliest opportunity and movement restrictions should be clearly documented within one hour of imaging reporting.”

“Interpretation of cervical imaging in the presence of severe degenerative disease can be challenging. Escalation for specialist reporting should be included in local trauma protocols to prevent delays in decisions regarding immobilisation.”

For patients who cannot tolerate immobilisation — “particularly those with dementia, delirium or coexistent traumatic brain injury” — a senior clinician should weigh comfort optimisation, delirium reduction strategies, the risk/benefit of immobilisation itself including the risk of pneumonia and aspiration, and the risk/benefit of sedation. On that last point the guideline is unambiguous: “Sedation is not without risk and should not be considered standard practice in these situations.”

Cord injury from a low-energy mechanism

“Although uncommon, there is increased risk of spinal cord injury (SCI) in older people due to degenerative disease and canal stenosis, with incomplete cord syndromes possible from relative low energy mechanisms. Network spinal injury pathways should include management of cord injury in older people including the incomplete cord syndromes.”

And a time standard that is easy to miss: “Older patients with SCI should be referred to spinal cord injury centres within four hours of identification of the injury as recommended in national guidance from the Multidisciplinary Association of Spinal Cord Injury Professionals (MASCIP).”

On the incidental finding problem: “Fragility fractures in the thoracic region are relatively common in older patients and are often incidental findings on imaging. Physical examination and imaging beyond plain films (CT or MRI) should aid in the determination of acuity in these injuries.” The four network pathways LMTS names are stable fractures for analgesia; unstable fractures for brace therapy; unstable fracture requiring surgical intervention; and highly unstable fracture for urgent intervention.

The imaging criteria themselves are in NICE NG232 and are worked through in the CT head & C-spine module.

“All older patients who present to the ED with a suspected pelvic fracture should be assessed by the trauma team.” And: “If a pelvic fracture is identified on X-ray after a low energy fall, then activation of the trauma team for a full trauma assessment is recommended.”

“A pelvic or sacral insufficiency fracture which commonly accompanies a simple pubic ramus fracture will at least cause back pain, and may render the pelvis unstable. Urgent CT should be requested in symptomatic older patient (pain, reduced mobility).”

“Code red or major haemorrhage protocols should be activated as for any adult patient with known or suspected haemorrhage. Vasoconstrictors should be avoided. Pelvic binders should be applied as part of haemorrhage control. However, caution must be exercised for long term application (more than 12 hours) in older patients with poor skin integrity.”

“All older patients with acetabular fractures should be referred to the MTC pelvic surgery service for expert advice and possible transfer. This referral should occur within 12 hours of radiological (CT) confirmation of the injury,” with IEP CT images and a documented lower limb neurological assessment.

Whole-body CT

“Use whole-body CT (consisting of a vertex-to-toes scanogram followed by CT from vertex to mid-thigh) in adults (16 or over) with blunt major trauma and suspected multiple injuries. Patients should not be repositioned during whole-body CT.” This identical wording appears in both NICE guidelines — NG37 recommendation 1.2.8 and NG39 recommendation 1.5.34.

“Each MTC and TU should have a policy for the reversal of warfarin and other anticoagulants following major trauma. PCC should be immediately available for every major trauma patient with life threatening bleeding. Anticoagulant reversal should be administered on arrival in older trauma patients (no longer than within one hour of decision to reverse).”

From the key principles: “Consider timely anticoagulant reversal during the initial assessment of all older trauma patients.”

Warfarin with intracranial bleeding

“Patients on warfarin with intracranial bleeding should receive prothrombin complex concentrate (PCC) in addition to vitamin K, unless the bleed is extremely small and risk of procoagulation is considerable. In those patients known or suspected to be on anticoagulants, an INR test should be completed as soon as possible. (Point of care testing may be required.)”

Factor Xa inhibitors in trauma

The LMTS consensus for a known or suspected life-threatening haemorrhage from trauma on rivaroxaban, apixaban or edoxaban: “Administer 25-50u/kg four-factor prothrombin complex concentrate (e.g. Octaplex ® or Beriplex®) and 5mg intravenous vitamin K as soon as possible after arrival at the ED. Vitamin K will not reverse the anticoagulant effect of a DOAC but may help correct any coagulopathy resulting from co existing vitamin K deficiency.” Ensure a tranexamic acid bolus has been given, and consult the on-call haematologist emergently if bleeding continues.

Note that this document dates from April 2021 and states that for factor Xa inhibitors “reversal agents are currently unavailable”. NICE TA697 recommends andexanet alfa — but only for life-threatening or uncontrolled bleeding in the gastrointestinal tract, which is not this patient. For traumatic haemorrhage the PCC route above remains the UK consensus.

Dabigatran

“Administer Idarucizumab 5g intravenously as soon as possible after arrival at the ED. If bleeding reoccurs and clotting times are prolonged then a second dose of Idarucizumab 5g may be required.”

Antiplatelets and restarting

For TBI, LMTS says “administration of platelets should be considered if the patient is taking any antiplatelet therapy” — a position that sits uneasily with the PATCH trial, which found higher odds of death or dependence with platelet transfusion in antiplatelet-associated intracerebral haemorrhage. PATCH studied spontaneous ICH rather than traumatic ICH, so it does not settle the traumatic case, but the tension is real and worth naming rather than resolving silently. See the reversal module.

On restarting: “In the absence of robust evidence in this field, individualised treatment plans balancing risk of thrombosis and bleeding made in collaboration with geriatric and neurosurgical teams are required. In minor TBI, early initiation of LMWH may be appropriate after admission. Timing of restarting anticoagulation should be clearly documented.”

The document separates six Standards — phrased as must — from ten Recommendations, phrased as should. The standards are the harder edge, and two of them apply to every injured older patient:

• “Hospitals must provide an Acute Frailty service for at least 70 hours a week, with the aim to complete a clinical frailty assessment within 30 minutes of a patient's arrival in the Emergency Department or SDEC unit.”
• “Pain scores must be obtained in all older aged patients at triage.”
• “The ED staff must support patients to remain as independent as possible whilst they remain in the ED.”
• “Each Emergency Department must have a Geriatric Emergency Medicine/Frailty lead.”
• “All staff working in the Emergency Department must complete dementia and delirium training.”
• “All EDs must have ready access to time critical medication used commonly by older people, such as Parkinson's Disease medication, insulin and anti-epileptic medicines.”

The introduction sets the frame the rest of this module rests on: “All older people have the right to a health and social care assessment and should have access to treatments and care based on need, without an age-defined restriction to services. Health services should not be ‘ageist’.”

The recommendations then open with this one:

“All EM staff should have protocols for the management of ‘silver trauma.’”

Its background section sets the clinical frame: “‘Silver trauma’ assessment should take into account the differing injury patterns and physiological responses (co-existent morbidities and polypharmacy) of the older person. Lower thresholds for CT scanning and high suspicion for occult injuries are central to safe and effective care; traumatic brain injuries and chest wall injuries are the most common cause of death. Departments must have clear protocols for common clinical scenarios eg. anticoagulation reversal, as well as admission pathways whether isolated injuries (eg. pubic rami fracture) or multi-system involvement.”

On frailty scoring

RCEM recommends that “ED staff should undertake Clinical Frailty Scale (CFS) scoring if it will make a meaningful difference to their ED management” — and repeats the qualifier in the background text, which is unusual enough to be deliberate. The CFS “is a tool for those aged 65 years and older. Many Emergency Departments use 75 years and older as the recommended age for frailty scoring.” It describes the patient's baseline two weeks before presentation, not how they look now.

LMTS makes the same point from the other direction: “Early frailty identification is to augment decision making and expedite access to specialist geriatrician services, not to deny access to care.”

This tool deliberately does not reproduce or calculate the Clinical Frailty Scale. It is a licensed instrument with its own descriptors and training requirements — use your department's licensed copy.

Pain

“Pain is often under recognised in the Emergency Department especially in older aged patients and those with a cognitive impairment such as dementia. If the patient is unable to communicate verbally, non-verbal cues should be looked for such as agitated behaviour and facial grimacing. The Abbey Pain Tool may be useful.” Ask the family or carer whether they think the patient is in pain, and how the team would recognise it.

Frailty syndromes, and the hip fracture bundle

“ED staff should be adept at recognising common frailty syndromes including, Frailty Delirium, Falls, Polypharmacy, suspected fracture neck of femur (#NoF) and end of life (EoL) care.”

“It should be recognised that delirium is a medical emergency with associated high rates of mortality and morbidity. Following identification of delirium, pathway should be initiated to help identify precipitants and provide appropriate acute management eg. TIME bundle.” The 4AT is the recommended assessment tool.

“Patients who have a clinical suspicion or confirmation of a hip fracture should have the Big Six interventions/treatments before leaving the ED (pain relief, delirium screen, NEWS2 score, bloods & ECG, pressure area assessment and IV fluids started).”

“Consider referral to community based teams if the patient has had two or more falls in the last 12 months or has problems with walking or balance.”

On medication: “For older aged patients a medication review is suggested, to include medication reconciliation, identification of polypharmacy, anticholinergic burden, drug interactions and side effects, compliance with medication and understanding of use. For older aged patients the STOPP/START tool is an example of a medication review tool. Any medication changes must be conveyed to the patients General Practice team and in writing to the patient.”

On escalation: “EDs should have ready access to Treatment Escalation Plans (TEPs) and Recommended Summary Plan for Emergency care and Treatment ReSPECT information. If there is an acute necessity for a ReSPECT conversation, i.e. it is thought the patient will die in the Emergency Department, effort should be made to include the patient and their nominated family members in the conversation.”

And on discharge: “An accurate and meaningful discharge letter and telephone handover is particularly important for patients who are unable to retain the information themselves or communicate it to care providers, such as those living with dementia. It is also useful to document the time last medications were given and any medication changes.”

From the LMTS executive summary: “All older major trauma patients should receive the same standards of care as for any other major trauma patient.” And on admission: “Older trauma patients should receive the same trauma care following admission as that given to younger adults (those under 65 years of age).”

The guideline also argues against the existence of documents like itself: “At a network, MTC and TU level there should not be a requirement to develop multiple clinical guidelines specifically for older major trauma. Given the identified and continued rise in the proportion of older patients within the trauma system, it is more appropriate that all local and network guidelines relating to trauma should include elements which are specific to older and/or frail patients.”

TARN's version of the same conclusion: “There are two distinct types of major trauma - high energy transfer trauma in younger patients and low energy transfer trauma in older patients. Each of these types account for about half of major trauma cases.”

The point of a silver trauma module is not that these patients need different care. It is that they need the same care, and the system is much less likely to give it to them.