How should I assess and manage an elderly patient with trauma, including imaging, reversal of anticoagulation (warfarin, direct oral anticoagulants, dabigatran), pain control, delirium prevention, early mobilization, deep‑vein thrombosis prophylaxis, and discharge planning?

Management of Elderly Trauma Patients

Activate trauma protocols early for all patients ≥55 years old and maintain a lower threshold for aggressive intervention, as elderly trauma patients have a 6.8% increased mortality risk for each year beyond age 65 and are frequently under-triaged due to their blunted physiological responses. 1, 2

Initial Assessment and Triage

Age Definition and Protocol Activation

• Consider patients ≥55 years old as "elderly" for trauma protocol purposes and activate early trauma response even for seemingly minor mechanisms of injury 1
• Use lower vital sign thresholds: heart rate ≥90 bpm and systolic blood pressure <110 mmHg (not the standard 120 mmHg) for trauma activation 1, 3, 2
• Recognize that 80% of geriatric trauma patients have at least one chronic disease that impairs their physiological reserve 1

Frailty Assessment

• Assess frailty in all elderly trauma patients immediately using the Geriatric Trauma Outcome Score (GTOS) or Trauma-Specific Frailty Index to predict mortality and poor outcomes 1
• Document comorbidities, medication history (especially anticoagulants and beta-blockers that mask tachycardia), and baseline functional status 1

Laboratory Evaluation

• Obtain early arterial or venous blood gas for baseline base-deficit and lactate levels as markers of occult hypoperfusion, which is common despite normal vital signs 1, 2
• Perform serial base deficit and lactate assessments to monitor resuscitation adequacy 1
• Check complete blood count, electrolyte panel, and coagulation studies (PT/INR, aPTT) immediately 3, 2

Imaging Strategy

CT Scan Threshold

• Maintain a low threshold for contrast-enhanced CT imaging in all geriatric trauma patients - the diagnostic yield far outweighs the risk of contrast-induced nephropathy given the catastrophic consequences of under-triage 1, 2, 4
• Perform liberal CT head imaging for any head trauma in anticoagulated patients, regardless of normal neurological examination 3, 2
• Image the cervical spine extensively, as spinal fractures are more common in elderly fallers 3

Anticoagulation Reversal

Assessment of Anticoagulation Status

• Rapidly identify all anticoagulant and antiplatelet medications during initial triage, as this guides resuscitative therapies and coagulative support 1
• For patients on direct oral anticoagulants (DOACs) like rivaroxaban, obtain chromogenic anti-FXa assay calibrated with the specific DOAC for quantitative drug level assessment 3

Warfarin Reversal

• Administer vitamin K and prothrombin complex concentrate (PCC) for warfarin-associated bleeding in trauma 1
• Target INR normalization rapidly in patients with intracranial hemorrhage or life-threatening bleeding 1

DOAC Reversal (Rivaroxaban, Apixaban, Edoxaban)

• Reserve reversal agents for life-threatening bleeding with dosable plasma DOAC levels - not all elderly patients on DOACs require reversal 3
• For rivaroxaban-associated life-threatening bleeding, administer andexanet alfa: low dose (400 mg IV bolus over 15 minutes, then 480 mg infusion over 2 hours) or high dose (800 mg IV bolus over 30 minutes, then 960 mg infusion over 2 hours) 3
• Consider that rivaroxaban clearance depends on renal function; patients with renal dysfunction have higher drug levels and longer half-lives 3

Dabigatran Reversal

• Administer idarucizumab for dabigatran-associated life-threatening bleeding 1

Critical Caveat

• Do not routinely reverse anticoagulation in all elderly trauma patients - only those with hemorrhagic shock not responding to resuscitation or life-threatening uncontrolled bleeding with measurable drug levels require reversal agents 3

Resuscitation Strategy

Fluid and Blood Product Management

• Minimize crystalloid fluids and emphasize early coagulative support in resuscitation protocols 1
• Monitor resuscitation endpoints through serial base deficit, lactate levels, vital parameter trends (heart rate, blood pressure, respiratory rate, urinary output), and mental status 1

Hemodynamic Monitoring

• Implement point-of-care ultrasound (POCUS) for cardiac function and blood volume assessment if skills are available 1
• Reserve invasive hemodynamic monitoring for critically ill patients with hypotension, significant injuries (Abbreviated Injury Score >3), or uncertain cardiopulmonary status 1
• Consider inotropic agents cautiously in selected non-responding elderly patients to target resuscitation 1

ICU Admission

• Admit elderly trauma patients to a dedicated intensive geriatric care unit for close monitoring of vital parameters and mental status 1

Pain Control

Multimodal Analgesia

• Administer intravenous acetaminophen 1g every 6 hours as the cornerstone of acute trauma pain management 5
• Implement multimodal approach including: acetaminophen, gabapentinoids, NSAIDs (with caution for renal function and bleeding risk), lidocaine patches, and tramadol 5
• Avoid opioids as first-line agents in elderly patients due to increased risk of delirium, respiratory depression, and falls 5

Delirium Prevention

Intraoperative Management

• Avoid intraoperative hypotension, as it correlates with postoperative delirium in geriatric patients 1
• Monitor mental status continuously as part of resuscitation endpoints 1

Deep Vein Thrombosis Prophylaxis

Timing and Agent Selection

• Initiate low molecular weight heparin (LMWH) or unfractionated heparin (UFH) as soon as bleeding is controlled 5
• Adjust dosing for renal function, patient weight, and bleeding risk assessment 5
• Balance the risk of venous thromboembolism against bleeding risk on a case-by-case basis 5

Early Mobilization

Physical and Occupational Therapy

• Involve physical therapy and occupational therapy early for all admitted elderly trauma patients 6, 7
• Perform comprehensive geriatric assessment (CGA) including mobility, activities of daily living, frailty, and depression screening 6, 7
• Document functional status and rehabilitation needs in the medical record 6

Discharge Planning

Safety Assessment

• Perform gait evaluation and "get up and go test" prior to discharge to ensure patient safety 3
• Evaluate underlying cause of falls including medication assessment, orthostatic blood pressure, comorbidities, and visual or neurological impairments 3
• Admit patients if safety cannot be ensured at home 3

Disposition Options

• Coordinate with case management early for appropriate placement: home (45%), rehabilitation units (26%), nursing homes (16%), or other facilities 8
• Communicate CGA findings and recommendations to the patient's primary care provider 6
• Discuss medication changes and additional therapy interventions with family 6

Common Pitfalls to Avoid

• Do not under-triage elderly patients based on seemingly minor mechanisms (falls from standing are now the most common cause of major trauma in this population) 1, 7
• Do not rely on normal vital signs to rule out significant injury - elderly patients have blunted physiological responses due to medications (beta-blockers) and baseline frailty 1, 2
• Do not delay CT imaging due to concerns about contrast nephropathy - the risk of missed injuries is far greater 1, 4
• Do not assume all anticoagulated patients need reversal - only those with life-threatening bleeding and dosable drug levels 3
• Do not use fall risk as the primary reason to withhold anticoagulation - stroke prevention benefit typically outweighs bleeding risk 3