Background

With improvements in health and social care in the last century, the over-65-year-old patient cohort makes up a quarter of the population in the developed world. In the year 2000, the number of persons aged 65 years and older represented just more than 12% of the US population; by 2050, they are expected to make up more than 21% of the total population and almost 39% of trauma admissions, with an increasing of more than 20%. Patients aged 80 years and older that represent the group of “oldest old” patients, will increase to nearly 20 million persons by the year 2030 [1, 2].

In 2020, more than one-fifth (20.6%) of the EU population was aged 65 and over [2].

The longer life expectancy of the world population, who adopt an active lifestyle, and the effect of aging on patients’ physiology sustain trauma and mortality. Age-related anatomical modifications such as decreased muscle mass and strength, bone density, and joint flexibility and physiological changes, including decreased vision and hearing, slower reflexes, poorer balance, impaired motor and cognitive function associated with unrecognised frailty, make caring for geriatric patients challenging [3, 4].

Trauma is the fifth leading cause of death when all age groups are considered, the fourth leading cause of death in those aged 55–64 years and the ninth leading cause of mortality in patients aged 65 years and older [4,5,6].

The most common mechanism of injury in patients aged ≥ 65 is the ground-level fall. Six percent of ground-level falls patients will sustain a fracture, and 10–30% of these patients will have polytrauma, being elderly people more likely to sustain fractures of the cervical spine, ribs, hip, and extremities. Mortality rate in this age-group is reported to be as high as 7% [7,8,9,10,11,12]. Prevention strategies, endorsed recently by several western countries, to reduce falls in elderly such as home-based exercise programs and home safety interventions are effective to reduce the risk of falling but they have limited applications in active and independent people in the immediate future because of their high costs for healthcare systems [10].

Motor vehicle crashes are the second most common mechanism of injury among older patients, and the most common cause of traumatic mortality [4,5,6,7]. About one-quarter of all older adult victims of motor vehicle crashes sustain a chest injury which can exacerbate preexisting cardiopulmonary disease and increases the risk of significant complications, including pneumonia and respiratory failure [4,5,6].

Older adults are second only to children as victims of pedestrian injuries, but account for the largest percentage of the auto-pedestrian fatalities. The highest mortality rate in geriatric trauma is among pedestrians struck by a vehicle [7, 11,12,13].

Elderly women are also at high risk of burn injury, mainly due to home accidents, caused mostly by fire and scalding [3, 14]. Burns can have a devastating effect on geriatric patients, in whom mortality is significantly higher than in younger adults for any size and localization burn [15].

Geriatric patients are especially vulnerable to assault (the fourth most common mechanism of injury), resulting in 10% of geriatric trauma admissions. Geriatric victims of violence are 5 times more likely to die compared with younger victims [7, 11, 12].

Geriatric trauma mortality is high because of preexisting medical conditions, frailty and poor physiological reserve in elderly victims [16,17,18,19]. Eighty percent of geriatric trauma patients have at least one chronic disease, such as hypertension, arthritis, heart disease, pulmonary disease, cancer, diabetes, or history of stroke [4 Grabo]. These comorbidities, when combined with frailty result in more vulnerability to stress.

This is the raison why elderly trauma patients cannot be managed like adult younger trauma victims [18]. Deep understanding of their physiology is essential to provide them with proper treatment [20]. Important issues in improving the management and clinical outcomes of geriatric trauma include: (1) avoiding under-triage; (2) early, targeted, and aggressive care; and (3) early admission to an Intensive Care Unit (ICU). To accomplish these points, we need to early assess and manage “frail” patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients so as to improve it and reduce futile procedures.

Methodology

According to PICO [21] criteria, the coordinator of the project identified research areas, main topics and questions correlated to geriatric trauma management to investigate. The main topics and PICO questions are summarized in the Table 1.

Table 1 Topics and PICO questions
Full size table

Six working groups of experienced acute care and emergency surgeons were constituted to carry out a focused systematic review about the topic assigned, using PubMed, EMBASE, Google Scholar, and the Cochrane Central Register of Controlled Trials databases. according to PRISMA methodology [22]. Literature search was concluded in May 2023, limited to articles in English language and focused on the analysis of previously published systematic reviews with/without meta-analysis, randomized controlled trials, and observational studies (retrospective, prospective, and registry studies). The coordinator supervised each step of literature searching, study selection, the final presentation of evidence and wrote the manuscript.

Each working group provided a focused draft and a variable number of statements and recommendations according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) [23]. The provisional statements and the supporting literature were reviewed and discussed by email/call conferences and modified if necessary. Controversies statements and recommendations were validated with a Delphi consensus of WSES experts [24].

The final manuscript was discussed during the WSES Congress held in Pisa in June, 2023. Comments and suggestions were implemented to improve the recommendations in the geriatric trauma management.

The recommendations are summarised in Table 2.

Table 2 List of recommendations
Full size table

Notes on the use of these guidelines

The 2023 WSES geriatric trauma guidelines are the result of an extensive review of the literature and a validation by a consensus of experts in the field. The statements and recommendations provided in this work do not represent a standard of practice but a suggested plan of care, based on the best available evidence and the consensus of experts, but they do not exclude other approaches as being within the standard of practice. These guidelines should be used and tailored by the treating surgeons and individualized for each patient depending on the setting and should not be followed blindly.

Results

Definitions

Key Question 1.1

Which trauma patient is defined as “old” at initial evaluation?

Statement 1.1.1

The chronological age does not correspond to the biological age. Aging is correlated with para-physiological changes in organ systems with altered response to trauma, compared with younger injured patients [QoE MODERATE B].

Statement 1.1.2

Patients aged ≥ 55 may require dedicated trauma care, because they may have high mortality rates after trauma [QoE LOW C].

Statement 1.1.3

The age of 65 is most often used referring to “old”, “elderly” or “geriatric” patients [QoE HIGH A].

Recommendation 1.1

We suggest early trauma protocol activation in patients aged ≥ 55 years old [Weak recommendation based on a low level of evidence 2C].

We recommend to carefully evaluate injured patients aged ≥ 55-year-old for potential high risk of mortality and to avoid under-triage [Strong recommendation based on a low level of evidence 1C].

Summary of evidence and discussion

There are different ways of defining elderly people. Statistics on ageing generally categorize older people as being above a certain age threshold. Despite that, different cut-off levels of age have been suggested, generally a patient is defined as “geriatric” when aged 65 years old. The United Nations (UN) noted in World Population Ageing 2019 that older people are commonly defined as those aged from 60 or 65 years or more, while the World Health Organisation (WHO) states that older people in developed world economies are commonly defined as those aged 65 years or more. The WHO uses an alternative definition, whereby an older person is defined as someone who has already passed the median life expectancy at birth [25].

In trauma management, recent data suggest that mortality as adjusted for injury severity scale (ISS) increases at the age of 70 years, making the age of 70 the cutoff at which to consider a patient with trauma elderly or geriatric [26]. This notion is distinct from Advanced Trauma Life Support (ATLS) teaching, which recommends transportation to a trauma center for any patient older than 55 years. The Eastern Association for the Surgery of Trauma (EAST) guidelines which defines patients older than 65 years as elderly [27, 28].

Recently, a large multicenter analysis of 255,099 patients reported a significant increase in mortality at ages of 55, 77, and 82 years suggesting that trauma patients older than 55 years have to be considered for inclusion in geriatric trauma protocols. Furthermore, patients aged above 77 and at 82 years may need additional specialized care considerations. As age increased, patients were more female, have more dementia, sustain a ground level fall, and are more likely to be discharged to a skilled nursing facility after admission for trauma [29]. Although there is no consensus on an age cutoff for a patient with trauma to be considered elderly, the age of 65 is most often used in the trauma literature. Nevertheless, patients aged 55 and older are at high risk for mortality after trauma.

Key Question 1.2

When is a patient considered “physiologically old” and does he/she deserve different management after (blunt or penetrating) trauma?

Statement 1.2.

Frailty, hearth diseases, hepatic diseases, renal diseases, and cancer according to their stage and severity are risk factors for mortality in trauma patients [QoE low C].

Recommendation 1.2

We suggest an early and rapid assessment of the patient including vital signs on presentation, mechanism of injury, injury severity and frailty including comorbidities and medication history to identify vulnerable trauma patients [Weak recommendation based on low level of evidence 2C].

We recommend assessing frailty in all elderly trauma patients [Strong recommendation based on a moderate level of evidence 1B].

Summary of evidence and discussion

Older adults are becoming increasingly involved in major trauma, which is often defined as an Injury Severity Score greater than 15 [30]. One-third of all injury-related deaths among males and two-thirds of such deaths among females occur in those aged 65 years or older. The care of major trauma in this growing age group remains challenging [27, 30,31,32,33]. Older patients with trauma are at risk for increased morbidity and mortality and prolonged hospital stay [26, 34,35,36]. Older patients experience major trauma from low-velocity mechanisms, such as falls from 1 m or less [37]. This may partially explain an under-triage of older patients, which delays activating the trauma team and transfer to a trauma center [38,39,40,41,42,43,44,45]. Chronological age is not a physiological age. Trauma outcomes in older patients are worse for those with comorbidity. A population-based study focused on assessing the impact of pre-existing conditions on mortality and morbidity in trauma patients older than 65 years. It enrolled 33,781 patients and showed an overall mortality of 7.6%. For each 1-year increase in age beyond age 65, odds of dying after geriatric trauma increased by 6.8%. When presenting vital signs, Glasgow Coma Scale (GCS) score, and ISS were adjusted for, hepatic disease, renal disease and cancer were risk factors for mortality. Furthermore, chronic steroid use increased the odds of death after geriatric trauma, whereas Coumadin therapy did not [16].

A prospective cohort study of 250 (median age of 80 years old) patients at a level I trauma center reported the frailty was present in 44% and was correlated with increased in-hospital complications such as cardiac, pulmonary, infectious, hematologic, renal, reoperation, and worse discharge disposition. Patients who died had more frailty [19]. Frailty is a syndrome of decreased physiological reserve and resistance to stressors, which results in worsening mobility and disability, hospitalizations, complications, and death [19].

Primary evaluation and triage of older people victims of a trauma, which includes clinical exam and objective assessment is challenging because of the physiologic differences between older and younger patients. Kehoe and colleagues [46] reported that older patients with a traumatic brain injury are often evaluated with a higher GCS score compared with younger patients. Heffernan and colleagues [47] reported also an increased mortality in patients aged 65 or older with trauma admitted with a systolic blood pressure less than 110 mm Hg (vs. > 95 mm Hg in younger patients) and heart rate greater than 90 beats/min (vs. > 130 beats/min in younger patients). In fact, older patients with trauma may have chronic occult hypoperfusion, which makes the presence of “normal” initial vital signs unreliable. Elderly patients frequently have higher blood pressure, therefore, a “normal” blood pressure may be hypotension in the elderly. Other examples include modification of conventional GCS cut-off values [48] and initial vital signs [47, 49] for older patients. Other authors have recommended using markers such as serum lactate level and base deficit [50,51,52,53,54] as alternative predictors of mortality. There is a need to modify trauma care of the elderly to improve the clinical outcome [55].

Primary evaluation/assessment

Key Question 2.1

Which injury (physiological and anatomical) scores are stronger predictors of outcome in evaluating elderly patients for trauma?

Statement 2.1.1

Geriatric trauma patients are usually under-triaged to trauma centers due to low energy mechanisms of injury, unreliability of vital signs, and the use of medications that can obscure the physiologic response to trauma. Specific triaging scores can be used to predict outcomes in geriatric trauma patients and guide the triage decision-making process towards transfer to a Level I trauma centers and aggressive treatment (QoE moderate B).

Recommendation 2.1

We suggest evaluating elderly patients for trauma through the Geriatric Trauma Outcome Score (GTOS) to predict in-hospital mortality and the Trauma-Specific Frailty Index to identify patients at highest risk of poor outcome [Weak Recommendation, based on Moderate Quality of Evidence, 2B].

Summary of evidence and discussion

Several scoring systems, with the purpose of supporting decision making, have been proposed to accurately predict outcomes for geriatric trauma patients. Age ≥ 65 years has shown to be an independent risk factor for increased mortality in trauma, controlled for the same Injury Severity Score (ISS), with a 2.4–5.6 greater risk of death [16, 26, 56, 57]. However, the risk of death from trauma seems to increase earlier, at the age of 56 [58]. With the purpose of predicting in-hospital mortality in patients over the age of 65 years, in 2015 Zhao et al. developed an objective tool based on the covariates of age, ISS and transfusion requirements during the first 24 h of care. The Geriatric Trauma Outcome Score (GTOS) (Fig. 1) uses a formula that is [age] + [2.5 × ISS] + 22 (if packed red blood cells transfused ≤ 24 h of admission). In practice it showed to accurately predict continuous odds of mortality across a spectrum of injury severity. In the original publication by Zhao et al., the area under the receiver operating characteristic curve for the GTOS model was 0.82 [59]. Afterwards, the Prognostic Assessment of Life and Limitations After Trauma in the Elderly (PALLIATE) consortium [60] confirmed that the GTOS accurately predicts an elderly trauma patient's probability of dying during the index admission after injury, with an area under the curve applied to the validation sample of 0.86. Conversely, the GTOS does not seem to be a reliable prediction of 1-year mortality [61].

Fig. 1
figure 1

The Geriatric Trauma Outcome Score (GTOS)

Full size image

Recently, Ravindranath et al. evaluated retrospectively all elderly trauma patients admitted to the State Trauma Unit (Western Australia) between 2009 and 2019. Of the 57.473 trauma admissions during the study period, 15.034 (26.2%) were ≥ 65-year old. The ability of the GTOS to predict mortality was good (area under the curve 0.838, 95% CI 0.821–0.855), and better than either age (area under the curve 0.603, 95% CI 0.581–0.624) or ISS alone (area under the curve 0.799, 95% CI 0.779–0.819) alone. Noteworthy, the GTOS score (area under the curve 0.683, 95% CI 0.591–0.775) was inferior to the APACHE III (area under the curve 0.783, 95% CI 0.699–0.867) in predicting mortality for patients requiring intensive care. The calibration of the GTOS was reasonable when the predicted risk of death was < 50%, whereas when the predicted risk of death was > 50%, the model tended to be over pessimistic by overestimating the risks of death [62].

Both the ISS and GTOS trauma scoring systems were confirmed to be predictive of mortality in the study by Egglestone et al., with an area under the curve of 0.66 (95% CI 0.59–0.74) for the ISS, and 0.68 (95% CI 0.61–0.76) for the GTOS. The optimal cut-off points were ≥ 28 and ≥ 142, for ISS and GTOS, respectively [63]. In the study by Jiang et al., compared with APACHE II and SAPS II (Simplified acute physiology score II), the ISS, NISS (New Injury Severity Score), and TRISS (Trauma and Injury Severity Score) appeared to be better predictors of in-hospital mortality in elderly trauma patients. The area under the curve for the ISS was 0.807, 0.850 for the NISS, 0.828 for the TRISS, 0.715 for the APACHE II, and 0.725 for SAPS II (Simplified acute physiology score II) [64].

Although the GTOS seems to predict mortality in elderly trauma patients quite accurately, this score highly relies on ISS judgments, which are known for their subjectivity and suboptimal inter-observer reliability [65].

By conducting a receiver operating characteristic analysis, Scherer et al. performed a comparison with GTOS and the Revised Injury Severity Classification II (RISC-II) Score on a total of 58.055 geriatric trauma patients (mean age 77 years). Univariable models led to the following variables: age 80 years, need for packed red blood cells (PRBC) transfusion prior to intensive care unit (ICU), American Society of Anesthesiologists (ASA) score 3, Glasgow Coma Scale (GCS) 13, Abbreviated Injury Scale (AIS) in any body region 4. The maximum GERtality constructed on these five-variable score was 5 points. A mortality rate of 72.4% was calculated in patients with the maximum GERtality score. Mortality rates of 65.1 and 47.5% were encountered in patients with GERtality scores of 4 and 3 points, respectively. The area under the curve for the accuracy of mortality prediction was 0.784 and 0.879 for the GTOS and the RISC-II, respectively, whereas the novel GERtality score yielded an accuracy of 0.803. The new GERtality score seems to be an user-friendly and adequate in-hospital mortality prediction model for severely injured geriatric trauma patients, as it includes only five easily assessable patient variables, which makes it practical and simple to calculate. However, further studies should validate the novel GERtality score on different datasets [66].

The Trauma-specific Frailty Index (TSFI) (Fig. 2), including frailty, is a modified 15-component scale validated in 200 patients; it has shown to be useful in planning discharge disposition of elderly trauma patients [67]. In a prospective cohort follow-up study conducted on 250 geriatric trauma patients at a Level I trauma center at the University of Arizona (the 44% of whom were classified as frail according to the TSFI), patients with frailty were more likely to have in-hospital complications (odds ratio, 2.5; 95% CI 1.5–6.0) and adverse discharge disposition (odds ratio, 1.6; 95% CI 1.1–2.4). The mortality rate was 2.0%, and all patients who died were frail [19]. Similarly, the Clinical Frailty Score (CFS) was found able to discriminate older patients at risk of higher mortality, delirium and increased care requirements at discharge. A large prospective study looking at frailty and trauma in older people in the UK have shown the CFS to be a useful tool to identify adverse post-injury outcomes in geriatric (≥ 65 years) trauma patients. This study showed that effect of frailty on mortality persists in less severe injury patterns with ISS ≤ 15. Frail patients had lower ISS (median 9 vs. 16) but greater 30-day mortality [68]. In kee** with these results, Cheung et al. performed a 4-year retrospective cohort study with 266 patients 65 years and older admitted to a level I trauma center, and found that pre-admission frailty as per the CFS (CFS 6 or 7) was independently associated with adverse discharge destination (odds ratio 5.1; 95% CI 2.0 to 13.2) [69].

Fig. 2
figure 2

The Trauma-specific Frailty Index (TSFI)

Full size image

The study by Hamidi et al. compared the predictive ability of different frailty scores to predict complications, mortality, discharge disposition, and 30-day readmission in trauma patients. The TSFI and the Rockwood Frailty Score (RFS) were found better predictors of outcomes compared with the modified Frailty Index (mFI) and the International Association of Nutrition and Aging 5-item a frailty scale (FS) [70].

Available data support the inclusion of a frailty assessment through the Trauma-Specific Frailty Index in the trauma evaluation for the geriatric population, to identify patients at highest risk of poor outcome.

Key Question 2.2

Which clinical features do better define the hemodynamic instability in geriatric trauma patients?

Statement 2.2.1

Most geriatric patients have hypertension, cardiovascular disease, and impaired sensitivity to catecholamines. They can be on chronic medications such as beta-blocker therapy that can affect heart rate and blood pressure, blunting the systemic response to injury and significant blood loss with the absence of early tachycardia (QoE B moderate).

Statement 2.2.2

Geriatric patients should have appropriate assessment of their poly-pharmacologic profile as soon as possible after admission. They should be screened for beta-blockers, steroids, antiplatelet and anticoagulant medications. The frequent use of anticoagulant (warfarin, coumadin, dabigatran, rivaroxaban) and antiplatelet (clopidogrel, aspirin) medications in the geriatric population, puts these patients at high risk for significant bleeding events, even after minor trauma (QoE B moderate).

Recommendation 2.2

We recommend kee** a lower threshold for trauma protocol activation in geriatric patients, with triage set points of heart ratio 90 bpm and systolic blood pressure less than 110 mmHg [Strong Recommendation, based on Moderate Quality of Evidence, 1B].

Summary of evidence and discussion

Falls are the main cause of trauma in the geriatric population, accounting for 75% of cases, and are often low-level from standing or sitting height [16, 71,72,73].

Hashmi et al. investigated mortality rates in severe injured geriatric subjects aged ≥ 65 years and found that trauma patients aged ≥ 74 years were at a higher risk for mortality (overall mortality rate: 14.8%, 95% CI 9.8%-21.7%) than the younger geriatric group. Severe, extremely severe injuries, increasing age, and low systolic blood pressure at the presentation among geriatric trauma patients were found significant risk factors for mortality. Combined odds of dying in trauma patients older than 74 years was 1.67 (95% CI 1.34–2.08) compared with the elderly population aged 65 years to 74 years, but the odds of dying in patients 85 years and older compared with those of 75 years to 84 years was not different (odds ratio 1.23; 95% CI 0.99–1.52). A pooled mortality rate of 26.5% (95% CI 23.4–29.8%) was observed in the severely injured (ISS ≥ 16) geriatric trauma patients. Compared with those with mild or moderate injury, the odds of mortality in severe and extremely severe injuries were 9.5 (95% CI 6.3–14.5) and 52.3 (95% CI 32.0–85.5), respectively. Low systolic blood pressure had a pooled odd of 2.16 (95% CI 1.59–2.94) for mortality [74].

A systematic review and meta-analysis conducted by Sammy et al. in 2016 showed that trauma patients aged ≥ 75 had higher mortality rates than younger patients aged 65–74 years. Men had a significantly higher mortality rate than women (cumulative odds ratio 1.51, 95% CI 1.37–1.66), and patients with pre-existing comorbidity reported a higher risk of death. In particular, two studies that were evaluated in the systematic review reported increased mortality in patients on warfarin (cumulative odds ratio 1.32, 95% CI 1.05– 1.66). Higher mortality was found in patients with lower Glasgow Coma Scores and systolic blood pressures. Mortality increased with increased injury severity and number of injuries sustained. Low level falls were associated with higher mortality than motor vehicle collisions (cumulative odds ratio 2.88, 95% CI 1.26–6.60) [75].

Polypharmacy, defined as simultaneous co-administration of more than five medications, is often found in elderly people [76]. Fifty percent of geriatric patients have hypertension, 30% have heart disease, and 10% have diabetes, dementia, stroke, chronic pulmonary obstructive pulmonary disease, arrhythmias, or endocrine dysfunction [17].

The comorbidity–polypharmacy score (CPS) is able to quantify the magnitude of comorbid conditions using the number of co-administered medications as a measure of the “intensity” of therapy required for associated comorbidities [77]. Several studies have shown a negative association between polypharmacy and trauma outcomes, noting that higher CPS was associated with greater mortality, complications, longer hospital and intensive care unit stay, and need for discharge to a facility [77, 78].

Systolic blood pressure (SBP) and shock index (SI) are solid indicators of hemodynamic instability and the need for transfusion in the general trauma population [79, 80]. SI is also an accurate and specific predictor of morbidity and mortality in geriatric trauma patients. In the large study by Pandit et al. (217.190 geriatric trauma patients included), patients with SI greater than or equal to 1 were more likely to require blood products. Moreover, an SI greater than or equal to 1 was associated with the need of an exploratory laparotomy and the occurrences of in-hospital complications. The overall mortality rate was 4.1%, with an SI ≥ 1 being the strongest predictor for mortality (odds ratio, 3.1; 95% CI 2.6–3.3). With this in mind, geriatric trauma patients with SI ≥ 1 should be transferred to a Level 1 trauma center [81].

However, several studies have shown that SBP and SI cutoff points vary depending on the cause of trauma, pre-existing patient's illness, age, hypertension, and medication such as beta- or calcium channel blockers [78, 82, 83].

Park et al. retrospectively analyzed 4.681 trauma patients referred to a Level 1 trauma center between 2017 and 2018 with the aim to assess the utility and cutoff points of SBP and SI for predicting massive transfusion according to patients’ age and antihypertensives taking. There were 1.949 patients aged 65 years or older (41.6%), and 1.375 hypertensive patients (29.4%) in this study. Massive transfusion was given to 2.9% of patients, and 30-day mortality rate was 6.3%. In geriatric trauma patients taking antihypertensives, a prehospital SBP less than 110 mmHg was the cutoff value for predicting massive transfusion in multivariate analyses, whereas emergency department SI greater than 1.0 was the cutoff value for predicting massive transfusion in patients who were older than 65 years and were not taking antihypertensives [84].

Hemorrhage and hypoperfusion can be missed in this population because vital signs do not reflect shock response. Medication, such as beta-blockers and comorbidity including hepatic and renal impairment, previous or ongoing malignancy, and chronic steroid use, can further increase the mortality risk in geriatric trauma patients by up to five times [16]. Geriatric blunt trauma patients warrant increased vigilance despite normal vital signs on presentation. Triage set points of heart ratio 90 bpm should be considered in these patients, and lower threshold for trauma protocol activation is recommended, because in cases of under-triage of geriatric trauma patients, discharge disability and mortality rate are increased up to four times greater than younger adult patients [72].

The classic definition for hypotension in adults (90 mmHg) is linked to significantly greater mortality in the geriatric population [85].

The U.S. National Trauma Triage Protocol (NTTP) developed by the American College of Surgeons' Committee on Trauma and the Centers for Disease Control recognized that systolic blood pressure less than 110 mmHg may represent shock in patients older than 65 years [86]. Similarly, in a large retrospective cohort study on 902.852 trauma victims, Oyetunji et al. showed that optimal emergency department systolic blood pressure cutoff values for hypotension were 85 mmHg for patients aged 18–35 years, 96 mmHg for patients aged 36–64 years, and 117 mmHg for elderly patients [85].

Heffernan et al. performed a Level 1 trauma center retrospective chart review of heart rate and blood pressure at presentation in 2.081 young (aged 17–35 years) and 2.194 geriatric (aged 65 years or older) blunt trauma victims. They found that mortality increased considerably in the elderly patients for heart rates 90 bpm, whereas this association was not seen until hearth rate of 130 bpm in the young group. Moreover, mortality significantly increased with systolic blood pressure less than 110 mmHg in the geriatric patients, but not until a systolic blood pressure of 95 mmHg in the young patients [47].

Brown et al. evaluated the impact of substituting a SBP of less than 110 mmHg for the commonly recognized SBP of less than 90 mmHg criterion within the context of the triage protocol on triage performance and mortality in geriatric trauma patients. The study included 1.555.944 patients and demonstrated that a SBP < 110 mmHg had higher sensitivity but lower specificity in the geriatric cohort of patients (13 vs. 5%, 93 vs. 99%). The area under the curve was higher for SBP of less than 110 mmHg individually in both geriatric and adult cohorts. Within the NTTP, the area under the curve was similar for SBP of less than 110 mmHg and SBP of less than 90 mmHg in geriatric patients. Substituting SBP of less than 110 mmHg resulted in an under-triage reduction of 4.4% with an increase of overtriage of 4.3% in the geriatric cohort. In summary, this study demonstrated that implementing the SBP of less than 110 mmHg criterion in geriatric trauma patients results in discrimination as good as the current SBP of less than 90 mmHg criterion, but with superior improvements in under-triage relative to over-triage [87].

The implementation of these recommendations results in more timely care for geriatric patients and leads to faster mobilization of important resources in the emergency department.

Key Question 2.3

Which laboratory tests and biological markers are useful to evaluate the elderly trauma patient before resuscitation?

Statement 2.3.1

Occult hypoperfusion is often under-estimated in the geriatric trauma patient. A prompt assessment of base-deficit and lactates levels should be performed to identify those patients who need resuscitation and admission to an ICU. Elevated lactate and base deficit are definitely strong predictors of mortality within 24 h from hospital admission (QoE moderate).

Recommendation 2.3

We recommend performing an early blood gas (arterial or venous) for baseline base-deficit or a lactic acid assessment in geriatric trauma patients [Strong Recommendation, based on Moderate Quality of Evidence, 1B].

Summary of evidence and discussion

Decreased physiologic reserve results in relative intolerance to hypoperfusion and increased risk of multiorgan failure and death in the geriatric trauma patient [88].

Comorbidity and polypharmacy may mask the hemodynamic responses to hypovolemic shock. The Eastern Association for the Surgery of Trauma guidelines estimated under-triage rates of nearly 50% among geriatric trauma patients [57], this trend being likely because of the presence of occult hypoperfusion, and injuries associated with low-energy mechanisms of trauma. However, with a prompt recognition of the traumatic injuries, and aggressive resuscitation, up to 85% of geriatric trauma patients return to their pre-injury functional levels [89].

In hemodynamically stable elderly trauma patients, the identification and treatment of occult hypoperfusion are particularly challenging. Reliable triage tools for identifying the at-risk geriatric trauma patient are critical, as prolonged occult hypoperfusion in these patients increases mortality from 12% to nearly 35% [88]. In the general trauma population, lactate and base deficit are reliable markers of blood perfusion and have been shown to be highly sensitive in the identification of high-risk trauma patients [90, 91].

Schulman et al. evaluated the effects of prolonged occult hypoperfusion on mortality in 195 younger (mean 56 years) and 69 elderly (mean 55 years) blunt trauma patients. This study found that elevated arterial lactate at admission and prolonged clearance times were proxies for prolonged occult hypoperfusion and predicted increased ICU admission and overall mortality. Specifically, elderly trauma patients with admission arterial lactate greater than 2.4 mmol/L had mortality rates of 34.6% compared with 11.6% for patients with normal lactate. By comparison, patients less than 55 years of age with elevated lactate had mortality rates of 4.6% [88]. In the same line, compared with a hospital survival rate of 85% to 86% for elderly normotensive patients with normal blood base deficit or lactate concentration upon emergency department arrival, the results of the study by Callaway et al., indicated a significantly decreased hospital survival rate of 60% associated with blood base deficit of 6 mEq/L or lactate concentration of 4 mmol/L upon hospital arrival. Mean lactate was significantly higher in non-survivors compared with survivors (2.8 mm/L ± 1.8 mm/L vs. 2.0 mm/L ± 1.0 mm/L). Patients in the severely elevated lactate group had 4.2 increased odds of death compared with the normal lactate group. Similarly, base deficit was more abnormal in non-survivors compared with survivors (2.3 mEq/L ± 5.2 mEq/L vs. 0.28 mEq/L ± 1.0 mEq/L). Normal, moderate, and severe base deficit were associated with mortality rates of 14% (95% CI 10.3–17.1%), 27% (95% CI 20.1–34.2%), and 40% (95% CI 24.9–54.1%), respectively [50]. Patients with a lactate 2.5 mmol or greater were 3.7 times more likely to die than those with a lactate less than 2.5 mmol (95% CI 1.6–8.2) in the study by Neville et al. The odds for mortality was 5.2 (95% CI 2.5–11.2) in patients with a base deficit of − 4 or less [92]. Early identification and treatment of occult hypoperfusion in geriatric patients with trauma using venous lactate-guided assessment and early trauma surgeon involvement is associated with significantly lower mortality [93].

Geriatric trauma patients have lower hemoglobin levels on admission, and persistently lower hemoglobin levels on discharge compared with younger trauma patients, despite they receive more blood transfusions [94], suggesting that aging may have a negative impact on post-injury anemia. Acute and subacute anemia is common among geriatric trauma patients, and they appear to respond less well to blood transfusion compared with young trauma patient. Moreover, as anticoagulant and antiplatelet medication use in trauma patients has been associated with increased risk of bleeding from minor injuries, elevated severity of injury, and increased mortality [6, 95].

In the study by Williams et al., warfarin anticoagulation was associated with increased mortality after trauma in the geriatric patient (mortality for patients with an INR > 1.5 was 22.6%, versus 8.2% for those with an INR < 1.5). The logistic regression gave an age and ISS adjusted odds of death of 30% for a one-unit increase in INR (OR 1.3, 95% CI 1.1–1.5). This correlates to an age and injury score adjusted odds of death of 2.5 for an INR > 1.5 (95% CI 1.2–4.2). As elderly patients are commonly anticoagulated, considering the increasing number of indications for and prevalence of anticoagulation, the low cost of an INR dosage and the potential reduction in costs associated with traumatic brain injury, the assessment of a coagulation profile in elderly trauma patients is recommended to identify earlier those in need of closer monitoring and a more aggressive reversal of their anticoagulation [96].

Major trauma is also associated with a higher incidence of sepsis and multiple organ dysfunction, as a result of tissue damage, hypotension, hypoxia, cytokine release, and inflammation. Early identification of elderly patients at risk of develo** post-traumatic complications is important for outcomes.

Al Rawahi et al. reviewed 19 observational studies that showed a strong correlation between initial procalcitonin levels and ISS. Twelve studies demonstrated significant elevation of initial procalcitonin levels in patients who later developed sepsis after trauma. Procalcitonin level was a strong predictor of multiorgan failure in seven studies, making it a promising as a surrogate biomarker for trauma [307] alongside with pathological contact with the outside environment in penetrating trauma. Seventy percent to 90% of severe thoracic trauma patients may need tube thoracostomy [308]. Tube thoracostomy treats both pneumothorax and hemothorax, evacuating the content of the thoracic cavity and reducing the incidence of subsequent empyema. Nevertheless, the post-traumatic empyema rate varies from 2 to 25%, with S. aureus being responsible for 35–75% of subsequent infections [308]. Presumptive antibiotic use in thoracostomy has a clear role in preventing infectious complications in chest trauma patients. When stratified by trauma type, antibiotic prophylaxis showed to be protective in penetrating injuries, against empyema and pneumonia. In blunt trauma, antibiotics showed no protective effect against empyema or pneumonia [309, 310].

Other studies [311, 312], showed that in patients with blunt or penetrating thoracic trauma requiring the insertion of a chest drain, the administration of an antibiotic prophylaxis was associated with a reduced risk for post-traumatic empyema and pneumonia.

Further studies are required to define the optimal type, dose, and duration of antibiotic administration in thoracic trauma patients and in the elderly.

Traumatic limb fractures

Fractures are common in geriatric population and SSI is a significant post-operative complication after open reduction and internal fixation of traumatic fractures. A metanalysis was carried to evaluate the risk factors of SSI after open reduction and internal fixation of ankle fracture. It showed that BMI, ASA ≥ 3, diabetes, alcohol, open fracture, subluxation/dislocation, incision cleanness grade 2–4, high-energy injury mechanism, chronic heart disease, history of allergy, and use of antibiotic prophylaxis were identified as risk factors for the development of SSI after open reduction and internal fixation of ankle fracture [313].

A randomized double-blinded placebo-controlled trial showed that there is no statistically significant difference between patients who received prophylactic postoperative cefazolin for 23 h versus placebo although it decreased the risk of SSI after open reduction and internal fixation of closed extremity fractures. Patients with diabetes mellitus are more likely to develop SSI [314].

There is evidence supporting the use of antibiotic prophylaxis in the management of open fractures [315]. Short course, single agent regimens using cephalosporins in order to prevent adverse outcomes in open fractures is the recommended approach. However, there is no conclusive evidence supporting prophylactic antimicrobial use in the management of small soft tissue upper extremity trauma and simple lacerations. The updated Surgical Infection Society guidelines recommend against administration of extended-spectrum antibiotic coverage compared with gram-positive coverage alone to decrease infections complications, hospital length of stay or mortality in type I or II open extremity fractures. In type III open extremity fractures, it is recommend to administer an antibiotic therapy for no more than 24 h after injury, in the absence of clinical signs of active infection, to decrease infectious complications, hospital length of stay or mortality. SIS recommends against extended antimicrobial coverage beyond gram-positive organisms to decrease infectious complications, hospital length of stay or mortality. In type III open extremity fractures with associated bone loss, it is recommended to administer antibiotic therapy in addition to systemic therapy to decrease infectious complications [316].

There is promising literature on the beneficial effects of the use of local antibiotics, e.g. by antibiotic beads in managing traumatic fractures. Coating of internal fixation devices is a modern approach to improve infection prophylaxis and gentamicin-coated implants have been demonstrated to be safe in clinical application [317, 318].

Burn patients

Infections among burn patients are common and are associated with high mortality rate. In a series of 175 patients with severe burns, infections preceded multiorgan dysfunction in 83% of patients and were considered as the direct cause of death in 36% of patients [319].

Systemic antibiotic prophylaxis administered in burn patients in the first 4–14 days significantly reduced all cause mortality by nearly a half; limited perioperative prophylaxis reduced wound infections but not mortality. Topical antibiotic prophylaxis applied to burn wounds had no beneficial effects [320].

Barajas-Nava [321] reviewed 36 RCTs (2117 participants); twenty-six (72%) evaluated topical antibiotics, seven evaluated systemic antibiotics (four of these administered the antibiotic perioperatively and three administered upon hospital admission or during routine treatment), two evaluated prophylaxis with non absorbable antibiotics, and one evaluated local antibiotics administered via the airway. There was a statistically significant increase in burn wound infection associated with silver sulfadiazine compared with dressings/skin substitute (OR = 1.87; 95% CI: 1.09 to 3.19, I(2) = 0%), with significantly longer length of hospital stay compared with dressings/skin substitute (MD = 2.11 days; 95% CI: 1.93 to 2.28). Systemic antibiotic prophylaxis was evaluated in three trials (119 participants) and there was no evidence of an effect on rates of burn wound infection. Systemic antibiotics (trimethoprim-sulfamethoxazole) were associated with a significant reduction in pneumonia (only one trial, 40 participants) (RR = 0.18; 95% CI: 0.05 to 0.72) but not sepsis (two trials 59 participants) (RR = 0.43; 95% CI: 0.12 to 1.61). Perioperative systemic antibiotic prophylaxis had no effect on any of the outcomes of this review. There was a statistically significant increase in rates of MRSA associated with use of non-absorbable antibiotics for selective decontamination of the digestive tract with non-absorbable antibiotics plus cefotaxime compared with placebo (RR = 2.22; 95% CI 1.21 to 4.07).

The role of an adequate source control including surgical removal of contaminated material and areas of necrosis and protection of the exposed lesion is crucial in decreasing the infective risk. Antibiotic prophylaxis could protect the high risk patients from infectious complications [305].

Key Question 5.2

How to control pain in elderly patients admitted for trauma?

Statement 5.2.1

Pain assessment is crucial in obtaining an effective pain control in elderly trauma patients (QoE B-C moderate-low).

Statement 5.2.2

Opioids administration should be avoided in elderly patients in the trauma setting to reduce side effects (QoE B-C moderate-low).

Statement 5.2.3

Multimodal analgesic approach or “balanced analgesia” including regional and peripheral nerve blocks and neuroaxial analgesia should be implemented in elderly patients pain control, in the trauma setting (QoE B moderate).

Statement 5.2.4

Regular intravenous administration of acetaminophen is effective and safe in elderly trauma patients (QoE B-C moderate-low).

Statement 5.2.5

Opioids administration for post-traumatic pain in elderly patient should consider a progressive dose reduction because of high risk of morphine accumulation and subsequent over-sedation, respiratory depression and delirium (QoE A high).

Statement 5.2.6

Non-pharmacological approaches play an important role in improving trauma pain, including immobilizing limbs and applying dressings or ice packs in conjunction with drug therapy (QoE C low).

Recommendations 5.2

We recommend a regular administration of intravenous acetaminophen every 6 h as first line treatment in managing acute trauma pain in the elderly in a multimodal analgesic approach [Strong recommendation based on high quality level of evidence 1A].

We suggest considering to add NSAIDs in elderly patients presenting with severe pain, taking into account potential adverse events and pharmacological interactions [Weak recommendation based on a moderate quality level of evidence 2B].

We recommend the implementation of Multi-Modal-Analgesia approach (MMA) in trauma setting for elderly injured patients including acetaminophen, gabapentinoids, NSAIDs, lidocaine patches, and tramadol and opioids only for breakthrough pain for the shortest period of administration at the lowest effective dose [Strong recommendation based on a moderate quality level of evidence 1B].

We recommend peripheral nerve blocks placement in elderly patients with acute hip fractures at the time of presentation to reduce preoperative and postoperative opioid use for analgesia [Strong recommendation based on a high quality level of evidence 1A].

We suggest the adoption of epidural analgesia and regional anaesthesia to control severe pain in acute hip fractures in selected elderly patients [Weak recommendation based on a moderate quality level of evidence 2B].

In elderly patients with ribs fractures, we recommend the association of systemic analgesic treatment with thoracic epidural and paravertebral blocks to offer an adequate pain control with limited contraindications and improvement in respiratory function, reducing opioid consumption, infections and delirium, if skills are available [Strong recommendation based on a high quality level of evidence 1A].

We recommend to routinely consider the use of epidural or spinal analgesia for management of postoperative pain in elderly patients who undergo major thoracic and abdominal procedures for trauma, if skills are available [Strong recommendation based on a high-quality level of evidence 1A].

We recommend carefully evaluating the use of neuraxial and plexus blocks for patients receiving anticoagulants to avoid bleeding and complications [Strong recommendation based on a high-quality level of evidence 1A].

We suggest the implementation of non-pharmacological measures such as immobilizing limbs and applying dressings or ice packs in conjunction with drug therapy, in control acute pain in elderly patients in the trauma setting [Weak recommendation based on a very low level of evidence 2D].

Summary of evidence and discussion

The treatment of pain in the elderly can be challenging particularly in patients with underlying cognitive impairment, who are less able to communicate. Patients with cognitive impairment would receive less pain medication, have poorer mobility, poorer quality of life and higher mortality than patients with intact cognition. Under-treated pain and inadequate analgesia increase stress and are risk factors for agitation, aggression, wandering, delay in mobilization, development of chronic pain, refusal of care and delirium in elderly patients [177, 322, 323].

The key steps in managing pain in trauma patients are the assessment of pain and the regularly evaluation of pain relief [322, 323].

Several studies demonstrated that the assessment and delivery of pain-relieving medication is suboptimal for geriatric trauma patients.

It was reported that 42% of patients over the age of 70 years old didn’t receive adequate analgesia, even when patients reported moderate to high level of pain after closed-isolated extremity and clavicular fractures [324].

One in three older adults presenting to the ED with non-operative fragility pelvic fractures receive no analgesia during the course of their prehospital and ED care [325].

A study evaluating the impact of age on pain perception in the ED, found that older adults experience the same level of pain as their younger counterparts from dislocations and fractures [326].

Pain assessment based on the patient’s self-report is the most accurate and reliable evidence of the existence of pain and its intensity for patients of all ages, regardless of communication or cognitive deficits [327].

For that, a variety of tools [328,329,330] were developed to quantify pain intensity, such as the numeric rating scale (NRS), rating pain from 0 to 1; the verbal descriptor scale (VDS), including series of phrases which descried different levels of pain intensity (e.g., “no pain,” “mild pain,” “moderate pain,” “severe pain,” “extreme pain,” and “the most intense pain imaginable”) and the faces pain scale (FPS), providing series of progressively distressed facial expressions to be choosen by the patient according to the severity or intensity of his/her current pain; and the visual analogue scale (VAS), consisting of a 10-cm line, with the left-hand side labeled “no pain” and the right-hand side labeled “most intense pain imaginable” (or similar descriptor).

The appropriate pain measurement scale should be selected according to individual’s ability to read, hear, and understand how to complete the tool.

In non-communicative older adults with cognitive impairment and dementia, the pain assessment can rely on observational and surrogate (family, certified nursing assistants) reports. Six main types of pain behaviors and indicators were described [331] including:

  • Facial expressions as slight frown, sad, frightened face, grimacing, wrinkled forehead, closed or tightened eyes, any distorted expression, rapid blinking;

  • Verbalizations, vocalizations as sighing, moaning, groaning, grunting, chanting, calling out, noisy breathing, asking for help;

  • Body movements such as rigid, tense body posture, guarding, fidgeting increased pacing, rocking, restricted movement, gait, or mobility changes;

  • Changes in interpersonal interactions such as aggressive, combative, resisting care, decreased social interactions, socially inappropriate, disruptive, withdrawn, verbally abusive

  • Changes in activity patterns or routines such as refusing food, appetite change, increase in rest periods or sleep, changes in rest pattern, sudden cessation of common routines, increased wandering.

  • Mental status changes such as crying or tears, increased confusion, irritability, or distress.

For patients with severe dementia, the Pain Assessment IN Advanced Dementia (PAINAD), the Functional Pain Scale, or Doloplus-2 are better than other tests. [332, 333]. In non-verbal patients who cannot provide self-report, pain behaviors such as guarding and grimacing and input from family and caregivers associated with the Critical care Pain Observation Tool (CPOT) and Behavioral Pain Scale (BPS) are valid tools [334].

In the treatment of acute pain in injured patients, drugs should be administrated early; they should be quick and easy to administer; have short half-life, high effectiveness, and minimal side effects.

The choice of drugs and appropriate methods of administration should consider the response to and the need for continuous analgesia in the management of the patient.

In trauma patients, medication selection must focus on those with the least negative effects on hemodynamic status of the patient.

Common analgesics used are opioids, N2O, paracetamol or acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs). The type of analgesics used are tailored according to the type of injury, pain severity, triage system, and patient’s clinical features [335].

A dutch double-blind, randomized, clinical trial including 182 patients treated with acetaminophen, 183 with diclofenac, and 182 with combination treatment, showed that acetaminophen is not inferior to non-steroidal anti-inflammatory drugs, or the combination of both, in minor musculoskeletal trauma [336].

Regular intravenous administration of acetaminophen every 6 h, unless contraindicated, is effective in traumatic pain relief. NSAIDs need to be used with caution in elderly patients due to their potential adverse events, such as acute kidney injury and gastrointestinal complication. In the perioperative pain management of elderly patients with hip fractures, NSAIDs are usually not recommended [337].

However, if NSAIDs are administrated for pain relief in elderly trauma patients a proton pump inhibitor should also be co-prescribed and particular attention should be paid to patients who are on angiotensin-converting enzyme inhibitors, diuretics or antiplatelets because of drug interactions [338].

Opioids are the cornerstone in the management of trauma patients and should be considered in moderate to severe pain. They are effective in pain control but associated with serious cardiovascular events, acute dyspeptic syndrome with nausea and vomiting and an increased risk of respiratory failure [339].

Elderly trauma patients are particularly vulnerable to opioid use disorders and the high risk of morphine accumulation and subsequent over-sedation and respiratory depression.

Oxygenation with assisted ventilation was required in 0.05% of patients treated with ketamine, in 0.02% of patients treated with fentanyl and in 0% of patients treated with morphine. Nausea and vomiting were the main adverse effects of morphine (4.8%), fentanyl (1.5%) and ketamine (0.5%), while hypotension occurred in 1.6% of cases with fentanyl and 0.5% of cases with morphine [340].

Tramadol is a centrally acting analgesic with 2 mechanisms of action: it has a weak opioid agonist activity and inhibits serotonin re-uptake. It has a reduced depressive effect on the respiratory and gastrointestinal systems in comparison with other opioids; however, confusion may be a problem for older patients. Tramadol may reduce the seizure threshold and is contraindicated in patients with a history of seizures [341].

Opioid use concomitantly with other central nervous system depressants (e.g., benzodiazepines, skeletal muscle relaxants, gabapentinoids, etc.) has to be avoided outside of specific clinical scenarios in highly monitored settings. N-methyl-D-aspartate receptor antagonists (ketamine, magnesium), membrane stabilisers (lidocaine), anticonvulsants (gabapentinoids), antidepressants (amitriptyline) and ∝-agonists (clonidine, dexmedetomidine) are administrated alone or in combination with other analgesics to improve their effect. When selecting an adjuvant agent, physicians should prescribe medications with the lowest side effect profile for the geriatric patient, titrate the drug slowly, and assess patients carefully for both effectiveness and the presence of adverse effects, which have to be anticipated and managed accordingly. Laxative therapy, such as the combination of a stool softener and a stimulant laxative should be prescribed in a patient treated with opiods [341].

Several alternatives to opioids were proposed in literature. Recently methoxyflurane, an inhaled non-opioid analgesic with a rapid onset of pain relief was approved in low-dose for emergency relief of moderate-to-severe trauma-related pain in adults. A recent multicenter, randomized, controlled, open-label trial in adult patients (age range 19–91 years) showed that inhaled methoxyflurane (3 mL) is effective in providing superior short-term pain relief to intravenous morphine in patients with severe trauma pain [342].

A meta-analysis was carried out to compare the efficacy and safety of low-dose methoxyflurane with standard of care analgesics in adults with trauma-related pain. This meta-analysis showed that pain intensity reduction was statistically superior with low-dose methoxyflurane compared with standard of care analgesics (overall estimated treatment effect = 11.88, 95% CI 9.75–14.00; P < 0.0001). Significantly more patients treated with methoxyflurane achieved response criteria of pain intensity ≤ 30 mm on a visual analog scale, and relative reductions in pain intensity of ≥ 30% and ≥ 50%, compared with patients who received standard of care analgesics. The median time to pain relief was shorter with methoxyflurane than with standard of care analgesics. The findings were consistent in the subgroup of elderly patients (aged ≥ 65 years) [343].

The multimodal analgesic approach (MMA) or “balanced analgesia” was introduced with the aim of decreasing the exposure to opioids, to address acute pain effectively, and enhance recovery after surgical procedure and trauma. It is defined as the integrated use of multiple strategies including systemic analgesics, regional analgesic techniques, and non-pharmacological interventions to affect peripheral and/or central nervous system sites in the pain pathway with the main aim of achieving a synergistic effect of the various classes of drugs used at lower analgesic doses [344,345,346,347,348,349].

MMA provides the use of: (1) analgesics, including opioids, nonopioid analgesics (such as acetaminophen and NSAIDs), the gabapentinoids (gabapentin and pregabalin), serotonin norepinephrine reuptake inhibitors, tricyclic antidepressants, and N-methyl-d-aspartate (NMDA) receptor antagonists; (2) neuraxial (epidural and intrathecal) analgesia; (3) peripheral nerve blocks; and (4) intra-articular and wound infiltration with local anaesthetics.

The synergy created when multimodal regimens are used to target discrete components of the peripheral and central pain pathways leads to effective analgesia at lower opioid dosing, reducing related risk and producing fewer adverse effects [343, 344, 349] MMA should be individualized in a muldisciplinary approach according to the patient; type of pain; mechanism of pain (inflammatory or neuropathic); type of surgical procedure; location of pain; expected duration of pain. Because of their opioid-sparing effects, multimodal strategies are useful and safe for elderly patients [345, 346].

The MAST (Multi-modal Analgesic Strategies in Trauma) study [345] was a randomized, pragmatic, trial aimed to compare the original multimodal analgesic protocol regimen (MMPR) (intravenous administration, followed by oral, acetaminophen, 48 h of celecoxib and pregabalin followed by naproxen and gabapentin, scheduled tramadol, and as needed oxycodone) and the MAST MMPR (oral acetaminophen, naproxen, gabapentin, lidocaine patches, and as needed opioids). This strategy used a fixed schedule of acetaminophen, gabapentinoids, non-steroidal antiinflammatory drugs (NSAIDs), lidocaine patches, and tramadol with stronger opioids available only for breakthrough pain. It was reported that MMA reduce opioid exposure with a substantial reduction in patient-reported pain scores. This is due to administering non-opioid analgesics (e.g., paracetamol and NSAIDs) on a scheduled basis, rather than as needed, to mitigate the fluctuations between peak and trough serum levels.

A secondary analysis of the MAST data, showed that older trauma patients require fewer opioids than younger patients with similar characteristics and pain scores. Opioid dosing for post-traumatic pain should therefore consider age. A 20 to 25% dose reduction per decade after age 55 may reduce opioid exposure without altering pain control [346].

Neuraxial and peripheral regional anesthesia

Regional analgesia is a crucial part of MMA. It includes peripheral nerve blocks (PNBs) with or without a continuous peripheral nerve block (CPNB) infusion directed toward an isolated nerve or plexus through the injection of a local anesthetic near the neural targets. These techniques allow a localized delivery of analgesia to specific painful areas and augment multimodal regimens [347].

Strong evidence confirm that the implementation of peripheral nerve blocks (PNBs) in managing acute pain associated with traumatic fractures in elderly patients is effective in decreasing the use of opioids, pain, and lenght of hospital stay [348].

In 2018, Steenberg et al. [350] made a systematic review of the literature (11 randomized and quasi-randomized controlled trials, with a total of 1062 patients) reported that the analgesic effect of fascia iliaca compartment block was superior to that of opioids during movement, resulting in lower preoperative analgesia consumption and a longer time for first request of analgesia, and reduced time to perform spinal anaesthesia. Block success rate was high and there were very few adverse effects. A Cochrane review (49 trials analyzed) was carried out to compare single shot PNBs used as perioperative, postoperative analgesia, or as a supplement to general anaesthesia versus no nerve block (or sham block) for adults with hip fracture. Three thousand sixty-one patients were enrolled; 1553 randomized to PNBs and 1508 to no nerve block with an average age of participants ranged from 59 to 89 years. PNBs reduced pain on movement within 30 min after block placement, risk of acute confusional state, chest infection, and time to first mobilization and probably costs [351].

A systematic review of 27 RCTs with 2478 cases assessed the use of fascia iliaca compartment block (FICB) as an analgesic strategy for perioperative pain management in geriatric patients with hip fractures after admission in the emergency department, and showed that this technique is safe, reliable, reproducible, and able to provide adequate pain relief compared with the conventional analgesia methods in the peri-ooperative management, promoting earlier mobilization, preventing complications, and reducing additional analgesic consumption [352].

Several studies investigated the efficacy of different type of PNB and showed a good pain control in patients presenting with hip fractures [353, 354].

The AnAnkle Trial, [355] a randomized blinded trial of two centers, which enrolled 150 patients reported that PNB anesthesia (ultrasound-guided popliteal sciatic and saphenous blocks with ropivacaine) decreased the postoperative pain intensity in primary ankle fracture surgery compared with spinal anesthesia and consequently the consumption of opioids, despite substantial rebound pain when PNBs subsided.

The prospective study carried out by Garlich et al. [356] in a level I trauma center focusing on 725 patients aged ≥ 65 yo reported that patients who received a preoperative fascia iliaca block (in single-shot, administering a 30- to 40-mL bolus of 0.25% bupivacaine with 1:200,000 epinephrine or in continuous, with a bolus of 10 to 20 mL of 0.2% bupivacaine, followed by a continuous infusion of 0.2% bupivacaine at 6 mL/h ending on the morning of postoperative Day 1) for hip fracture surgery consume less morphine preoperatively, with low rates of opioid-related adverse events.

Thompson et al. [357] prospectively randomized 44 patients into 2 groups to study the efficacy of a preoperative fascia iliaca compartment block in geriatric patients with fractures of the proximal femur. There was no significant difference in consumption of acetaminophen for mild pain, tramadol for moderate pain, or functional recovery between the 2 groups, but a statistically significant decrease in morphine consumption (0.4 mg vs. 19.4 mg, P = 0.05) and increase in patient-reported satisfaction (31%, P = 0.01). Using the same methodology in 97 patients randomized into 2 groups (experimental and no-block control), Schulte et al. [354] confirmed that single perioperative Fascia Iliaca Block (FIB) for patients with hip fracture surgery decrease opioid consumption and increase the likelihood to be discharged home. Similarly, the adoption of epidural analgesia (epidural infusion of bupivacaine/fentanyl or bupivacaine/morphine) and regional anesthesia are options for adequate pain relief in hip fractures [337].

Furthermore, PNBs administrated to patients with hip fractures and moderate cognitive impairment (a major risk factor for perioperative delirium) seem not to impact the cognitive status [358, 382]. Ketamine is efficacious as an analgesic in abdominal surgery, reduces opioid requirement, and can reduce the risk of the development of postoperative chronic pain. However, it is associated with the risk of postoperative psychiatric adverse effects [383, 384].

Magnesium reduces the requirement for opioids, improves analgesia, and can reduce the hyperalgesia seen with Remifentanil. Potential adverse effects of magnesium include hypotension and the prolongation of neuromuscular block [385]. Use of neuraxial and plexus blocks for patients receiving anticoagulants must be carefully considered and scheduled [386].

Key Question 5.3

When and how is indicated to administer thrombo-prophylaxis in elderly trauma patients?

Statement 5.3.1

The use of scoring systems to stratify the risk of venous thromboembolism (VTE) of elderly trauma patients is recommended (QoE C low).

Statement 5.3.2

Venous thromboembolism (VTE) pharmacological prophylaxis can be avoided in low risk elderly trauma patients (QoE C low).

Statement 5.3.3

Venous thromboembolism (VTE) pharmacological prophylaxis is recommended in moderate-high risk elderly trauma patients, if not controindicated (QoE C low).

Statement 5.3.4

Mechanical prophylaxis is recommended when pharmacological venous thromboembolism (VTE) prophylaxis is contraindicated (QoE C low).

Statement 5.3.5

Venous thromboembolism (VTE) pharmacological prophylaxis should be initiated as soon as possible in moderate-high risk patients and should be delayed of 24 h in case of Central nervous system injuries, active bleeding, coagulopathy, hemodynamic instability or solid organ injury (QoE C low).

Statement 5.3.6

Venous thromboembolism (VTE) pharmacological prophylaxis should be held in traumatic brain injury until computed tomography scan shows no progression (QoE C low).

Statement 5.3.7

Venous thromboembolism (VTE) pharmacological prophylaxis does not increase the rate of spinal hematoma in spinal injury (QoE C low).

Statement 5.3.8

Low Molecular Weight Heparin (LMWH) is recommended over un-fractionated heparin (UFH) to prevent deep vein thrombosis (DVT) (QoE C low).

Statement 5.3.9

The recommended dose of LMWH is 30 mg every 12 h. Dose adjustment according to anti-Xa levels and weight is warranted. In case of renal failure 5000 U of UFH every 8 h is recommended in elderly trauma patients (QoE C low).

Statement 5.3.10

Direct oral anticoagulants (DOACs) or aspirin may be considered as an alternative to heparin in view of better patient’s compliance after clinical stabilisation (QoE C low).

Recommendations 5.3

We recommend administering venous thromboembolism prophylaxis with LMWH or UFH as soon as possible in high and moderate risk elderly patients in the trauma setting according to the renal function, weight of the patient and bleeding risk [Strong recommendation based on a low quality level of evidence 1C].

If pharmacological prophylaxis of venous thromboembolism is contraindicated, we recommend mechanical prophylaxis [Strong recommendation based on a low quality level of evidence 1C].

Summary of evidence and discussion

The overall quality of evidence on the topic of venous thromboembolism (VTE) prophylaxis in elderly trauma patients is low as only observational retrospective studies and no RCTs are available. In addition, the vast majority of articles are on orthopaedic or neurologic trauma and very few articles include torso trauma. In order to achieve some recommendations, part of the indications were deduced from studies conducted on the general adult trauma population.

Trauma patients are at high risk of VTE mainly due to the reduction of mobility and to the inflammatory state generated by the trauma itself. For this reason VTE prophylaxis is usually recommended in these patients [387, 388]. The old age (> 60 years) has frequently been demonstrated to be an additional risk factor for VTE in trauma patients [389,390,391,392,393,394,395,396,397,398,399,400,401,402,403,404,405], as well as clearly mentioned also in the EAST guidelines for the management of VTE in trauma patients [399]. As a matter of fact, stratified age is among the major predictors of risk of VTE used to calculate both the Greenfield Risk Assessment Profile (RAP) [400] (Table 3) and the Trauma Embolic Scoring System (TESS) [401] (Table 4) which used in the recent Western Trauma Association guidelines algorithm for the management of VTE in trauma patients [402]. The 10 years retrospective study by Kim et al. [393] included 2500 elderly trauma patients (> 65 years old). The rate of VTE was 3.2%. Traumatic brain injury (P < 0.05); chest Abbreviated Injury Score > 3 (P < 0.001); mechanical ventilation (P < 0.001); major surgery (P < 0.001); and history of VTE (P < 0.05) were found to be independent predictors of VTE. Similarly, the 2 years retrospective study by Prabhkaran et al. based on a national trauma improvement program [392], selected 354,000 patients older than 65 years with post-traumatic VTE and demonstrated that being a male, ICU length of stay (LOS), overall LOS, spine injury, lower extremities injury, age > 75, severe traumatic brain injury, ventilator days, plasma transfusions within 24 h of admission were independent risk factors for deep vein thrombosis (DVT).

Table 3 Greenfield score < 5: low risk, >  = 5: high risk
Full size table
Table 4 TESS score 0–2: low risk. 3–6: moderate. 7–14: high risk
Full size table

According to the risk scores, the indication to VTE prophylaxis should be carefully evaluated. Low risk patients may not require VTE prophylaxis, while high risk patients should receive it. However, some critical conditions such as active bleeding, coagulopathy, hemodynamic instability, solid organ injury, traumatic brain injury or spinal trauma may need a delay of VTE pharmacological prophylaxis until stabilization. In these cases, mechanical prophylaxis (intermittent pneumatic compression, elastic stockings or mobilization) should be applied instead, if possible [403,404,405,406].

The large scale Norwegian national prospective observational study including 45.000 elderly patients undergoing osteosynthesis for hip fracture compared pre-operative and post-operative start of VTE prophylaxis. Pre-operative prophylaxis did not influence mortality or risk of reoperation in patients treated with osteosynthesis. However, post-operative prophylaxis decreased the risk of intraoperative bleeding complications for operations with hip compression screw, but not with intramedullary nail or screw osteosynthesis [405].

The Cochrane systematic review by Barrera et al. recommends prophylaxis to reduce the risk of DVT in severe trauma patients (RR 0.52). Although mechanical prophylaxis is effective in reducing the risk of DVT (RR 0.55), pharmacological prophylaxis seems more effective (RR 0.48), even if it may increase the risk of bleeding (RR 2.04). Low molecular weight heparin (LMWH) is preferable over unfractioned heparin (UFH) due to higher effectiveness in preventing DVT (RR 0.68). The association of mechanical and pharmacological prophylaxis further decreases the risk of DVT (RR 0.34). Neither mechanical nor pharmacological prophylaxis seem to reduce the risk of pulmonary embolism (PE) [387].

The retrospective cohort study by Campbell et al. based on a national database including 4000 elderly patients (> 60 years old), evaluated the effectiveness of factor XaI inhibitors compared to LMWH to prevent DVT after hip fracture surgery. Data did not show significant differences in DVT, bleeding or post-operative transfusions rates. However, the rate of PE was significantly higher in factor XaI inhibitors than LMWH (AR 2 vs -3.5). The authors concluded that factor XaI inhibitors may be a viable alternative to LMWH in view of patient’s preference and better compliance, despite their increased cost and lower efficacy in preventing PE [406].

The retrospective propensity score matching study of the American College of Surgeons Trauma Quality Improvement Program compared the use of UFH and LMWH in 40,000 elderly trauma patients (> 65 years old) to evaluate the risk of bleeding. LMWH was associated with a lower incidence of DVT (P = 0.007) and PE (P < 0.001), fewer bleeding complications and transfusions, P < 0.001, surgical procedures (P = 0.007), myocardial infarction (P < 0.0001), cardiac arrest (P = 0.001), severe sepsis (P < 0.001) and mortality (P < 0.001). Subanalysis by age group confirmed the lower rate of VTE (P = 0.003) and bleeding complications among patients ages > 75y receiving LMWH. Differences were more evident in ISS < 16. The authors conclude that LMWH is superior to UFH at preventing VTE events with fewer bleeding complication and should be therefore the drug of choice in most elderly patients with ISS > 16 [407].

The initial dose of LMWH enoxaparin for patients older than 65 years should be 30 mg every 12 h. In case of renal failure, UFH should is (5000 U every 8 h). Heparin dose adjusted according to anti-Xa levels improved the efficacy of VTE prophylaxis without increasing the rate of bleeding complications [408,409,410].

Management of the end of life in trauma setting for elderly patients

Key Question 6.1

Which are the clinical features and vital signs to define “end of life” in the elderly trauma patient?

Statement 6.1.1

There are no defined clinical features and vital signs to establish the elderly patient at end of life in trauma setting [QoE D very low].

Statement 6.1.2

Age alone is not an indication to withhold aggressive therapy [QoE C low].

Statement 6.1.3

To define the end of life in elderly patient in trauma setting is a very complex and delicate process. It should consider prognosis in regard to survival outside the acute care setting, the recovery of cognitive ability sufficient to perceive the benefits of treatment, the ability to resume physical activities, the patient’s advance directives, and the involvement of the surrogate decision-maker or healthcare proxy and of the family [QoE D very low].

Recommendation 6.1

We recommend discussing in a multidisciplinary approach the end of life in an elderly patient in the trauma setting. The decision should be considering the patient’s directives, family feelings and representatives’ desires and should be shared [Strong recommendation based on a low-very low quality of evidence 1D].

Summary of evidence and discussion

Withholding and withdrawing life support of elderly traumatic patients is a common occurrence in ICU, but, unfortunately, the futility of continued care and the definition of the end of life of a patient is not always obvious. Evidence shows that long-term functional outcomes of elderly trauma patients who survive their injuries can be good [411]. In a large retrospective study on 38,707 patients > 65 years old, 50% of the survivors were discharged to home [412] and in another study the 83% of patients ages 75 and older, who survived for 4 years after injury were living in an independent setting [413]. Available data indicate that age alone is not an indication to withhold aggressive therapy. Moreover, neither the perceived suffering of geriatric patients nor a poor anticipated quality of life should be used as the only criterion for withdrawal of support. In fact, most surgical ICU patients who survive, indicate that they would repeat the experience again if necessary [414] and that they have an “acceptable” quality of life and would undergo treatment again [415].

When determining whether ICU interventions are futile or not, clinicians must establish the prognosis in regard to survival outside the acute care setting and recovery of cognitive ability sufficient to perceive the benefits of treatment [416]. Such prognostication, however, can be difficult. Several scoring systems have been created and validated to predict in-hospital mortality of traumatic elderly patients. The Geriatric Trauma Outcome Score (GTOS) includes ISS, age, performance of packed red blood cell transfusion within 24h of admission as variables. It was externally validated on 18,282 subjects between the ages of 65 years and 102 years [59,60,61]. GTOS and Trauma Injury Severity Score (TRISS) were found to perform similarly and accurately in predicting the probability of death for injured elders. GTOS has the advantage of having fewer variables to be collected, and no reliance on data collected in the emergency room (ER) or by other observers, such as physiologic data. The AUC for GTOS ability to predict mortality in injured elders is 0.844 (95% CI 0.837–0.851) [60, 61].

The quick Elderly Mortality After Trauma (qEMAT) includes systolic blood pressure, pulse, GCS, presence of penetrating injury, story of congestive heart failure, chronic renal failure, and cirrhosis. It was retrospectively validated on 243,270 patients > 65 years old with an AUC of 0.87 (95% CI 0.86–0.87) for prediction of in-hospital mortality. This method outperforms GTOS, TRISS and age plus ISS [417]. The Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA score) includes age, Glasgow Coma sale (GCS), mechanism of injury, AIS sub-scores for head and neck (AIS-NH), and pelvis and extremity body regions (AIS-EXT), Charlson Comorbidity Index. It was prospectively validated for in-hospital mortality and for death 48h from admission on 1470 patients. The AUC for the STTGMA score ability to predict death within 48h from admission was 0.943 (95% CI 0.886–0.999) [418,419,420]. The modified 15 variable Trauma-Specific Frailty Index (TSFI) was retrospectively validated on 200 patients with age > 65 years presenting to a level 1 trauma center for predicting unfavorable discharge disposition (discharge to skilled nursing facility or death). The area under the curve was 0.829 [0.774–0.884]. Geriatric trauma patients with a TSFI cut-off score of > 0.27 are more likely to have unfavorable discharge disposition [67]. Other scores were created to predict the long-term prognosis and quality of life of these patients after discharge. The Palliative Performance Scale (PPS) derived from assessment of 5 domains: ambulation, activity level/evidence of disease, self-care, intake, level of consciousness. PPS has been initially shown to be correlated with survival in patients with advanced cancer. Then, it was prospectively validated for the ability to predict mortality and poor outcome at discharge and after 6 months in > 54 years old trauma patients. Low PPS patients fail to improve over time compared to high PPS patients [421, 422]. The FRAIL Questionnaire assesses five components: Fatigue, Resistance, Ambulation, Illnesses, and Loss of weight. It was prospectively validated on 188 patients > 65 years old admitted through the emergency department with a primary injury diagnosis. The FRAIL Questionnaire predicts 1-year functional status and mortality after trauma in patients > 65 years old and is a useful tool for bedside screening [423]. These scores could be used on admission for prognostication of short and long-term outcomes, and they could help in the management of these patients. However, there is no adequate level of evidence to recommend the routine use of these scores as potential trigger for palliative care in older trauma patients.

Focusing on brain injuries, patients aged above 65 years suffering traumatic brain injury have double in-hospital mortality compared to those younger than 65, and among the survivors elderly patients have higher healthcare utilization and worse early and long-term outcomes [424,425,426]. Western countries’ population is progressively aging and management of severely injured patients has drastically improved in the last decades. This leads to more patients surviving initial resuscitation and inevitably to the greater need of quality end-of-life care and palliative care. In this setting, the appropriate management of traumatic brain injury among elderly has become a public health requirement. The identification of patients whose therapeutic chances are reduced and who will least benefit from aggressive treatment becomes decisive to direct therapeutic efforts and to reduce medical futility. The Eastern Association for the Surgery of Trauma (EAST) guidelines and the American College of Surgeons Trauma Quality Improvement Program (ASC-TQIP) emphasized the importance of evaluating clinical improvement in the first 72 h (20). Severe trauma brain injury was defined as Glasgow Coma Scale (GCS) score 8 (20), and failure to improve in GCS within 72 h from the start of treatment is a negative prognostic factor associated with poor functional outcome or death despite aggressive treatment [427]. Patients who do not show signs of improvement within 72 h should be carefully evaluated before undergoing further aggressive treatment. The first 72 h constitute the critical interval to determine the prognosis. Unfortunately, the guidelines do not specify the parameters useful to quantify a neurological improvement although the persistence of a comatose state (GCS 8) at 72 h is certainly associated with a poor prognosis. It is evident that this time interval is absolutely arbitrary but certainly it represents the minimum time to assess the chances of survival and the effectiveness of the initial interventions. Age, per sè, is not considered a valid reason to limit the treatments available or to lead the decision to withdraw active treatment whilst frailty is a superior predictor of poor outcome [428,429,430,431].

A retrospective study of patients older than 65 admitted a Level I Trauma Center with severe brain injury (GCS >  = 8) documented that mortality was significantly higher in patients that do not show improvement in GCS score at 72 h. However, this significant difference was not recorded in the functional status at discharge and in the 12-month survival. Improvement to treatment at 72 h was not associated with better functional status and with better long-term survival. Then, among elderly, neurological status at 72 h is a good prognostic factor for in-hospital death but is not a valid tool to predict long-term outcomes for survivors [431].

Key Question 6.2

Could palliative management be useful in the management of an elderly patient at the end of life?

Statement 6.2.1

During the management of an elderly severely injured patient, the early insertion in the decision-making process of palliative medicine consultation improves outcomes, reduces in-hospital mortality and length of stay and improves communication with family, avoiding unnecessary operation [QoE C low].

Statement 6.2.2

Improved palliative care skill training for surgeons should be necessary to be more competent in end-of-life decisions [QoE D very low-quality].

Recommendation 6.2

We recommend involving as soon as possible the palliative care team in managing an elderly severely injured patient at the end-of-life status [Strong recommendation based on a low-very low quality level of evidence 1C].

Summary of evidence and discussion

In the last twenty years there has been an increase of the elderly population (older than 65 years) rate among hospital trauma-related admissions. These patients require almost the 25% of trauma-related health care resources due to their comorbidities and the decrease of physiologic reserve with high mortality [432,433,434,435]. The National Institutes of Health has estimated that the 5% of the most seriously ill Americans accounted for more than 50% of health care spending, with most costs occurring during the last 6 months of a patient’s life [430]. Racial and socioeconomic disparities in terms of utilization of hospice services were reported [433]. In US, Asian, African American, and Hispanic patients received less hospice care than Caucasian patients (OR 0.65, 0.60, 0.73; P < 0.0001). Race and ethnicity are independent predictors of a trauma patient’s transition to hospice care and significantly affect the length of stay [433]. However palliative management can be beneficial in the management of elderly injured patient. In such cases, when a patient sustains severe injuries that are unlikely to be fully recoverable, palliative care, including pain and symptom management, emotional and psychological support for the patient and his/her family, facilitating open and honest communication between the patient, their family and healthcare providers, can provide essential support and focus on the patient's comfort and quality of life, preserving the patient's dignity, comfort and enhancing their quality of life, regarding life-sustaining treatments and interventions. Palliative care teams collaboration in the setting of the end of life ensure that the patient's wishes regarding their care are known and respected, even if they become unable to communicate them later on [434, 435].

Palliative management in the context of an elderly injured patient at the end of life after trauma aims to provide holistic support, alleviate suffering, and improve the patient's overall well-being during their remaining time. It complements the efforts of the trauma team by focusing on comfort, dignity, and quality of life, while also supporting the patient's family throughout the process [434, 435].

Emergency and trauma surgeons have the responsibility to take important decisions in the end of life setting and in extreme situations; they need to be supported by the palliative care team, to respect the patient’s and family directives, share this decision and communicate it in the proper way.

End-of-life decision making is a variable process that involves prognosis, predicted functional outcomes, personal beliefs, institutional resources, societal norms, and clinician experience. An international survey showed that the admitting surgeon guided most end-of-life decisions, that formal medical futility laws are rarely available, that ethical consultation services are often accessible but rarely used, and typically unhelpful. Therefore the decision depends on type of injury, different religions, decision-maker viewpoint, and institutional resources and results in significant variation after trauma [436]. Palliative care physicians are more familiar and have more training in this complex decision making [437]. Moreover trauma surgeons can identify early patients who could die because of traumatic injuries, but they have the difficulty to estimate long-term outcomes [438]. It is crucial to highlight that palliative care is not only for patients at the end-of-life but is an approach that try to improve patient and their family’s quality of life and outcomes in case of life-threatening illness [438,439,440]. Despite these considerations and the growing importance of this topic, Ball et al. reported that palliative care consultation is underused. The most frequent barriers for patients and families to consultation are the resistance by families (40.2%), the concern for patient and family feeling that doctors are "giving up" (30.4%), the miscommunication regarding prognosis or diagnosis (27.4% and 16.2% respectively). Smoothing out these barriers could greatly increase treatments and outcomes in these category of patients [436].

Aziz et al. [439] carried out a systematic review to assess if geriatric trauma patients should receive post-injury care in a trauma center or not and if they should receive routine palliative care processes. They showed that for this group of patients, trauma center care was associated with improved outcomes in most studies and that the utilization of early palliative care consultations was generally associated with improved secondary outcomes, such as length of hospital stay. A study by Baimas-George et al. [432], based on a very large cohort of more than 16.000 emergency surgical patients who received palliative cares, showed that involving palliative care systems may be useful to decrease suffering, improve outcomes, and reduce non-beneficial and unwanted care. In this study 4% of patients were classified with an end-of-life disease (ELD): 3% received palliative care services, 5% were discharged to hospice, and 22% had an inpatient mortality. Authors reported that controlling for patient characteristics, utilization of palliative care services was associated with increased odds of discharge to hospice compared to inpatient mortality (OR 1.78 all patients and OR 2.04 for ELD).

In a retrospective study by Hoffman et al., 86.7% of trauma patients who underwent Withdrawal of Life-Sustaining Treatment after surgery received a palliative care consult. However, the short time between surgery and withdrawal of life-sustaining treatments suggested that increase palliative care system before surgery can help in decision-making process to avoid unnecessary surgeries [437].

Davies et al. in a monocentric retrospective study analyzed the impact of palliative care in management of femur fracture in high-risk patients [441]. The results confirmed that an early (24–72 h) intervention of palliative care is successful, also if mortality rates remain high. Similar conclusions were reported by Schuijt et al. [442], who found that a patient-tailored treatment associated with a decision-making multidisciplinary team can be helpful. The decision making rely on discretion to identify patients most appropriate for palliative management.

Stonko et al. reviewed data from a national trauma register including 614,496 geriatric trauma patients to assess if failure to rescue rate from any complication worsens with age and injury severity and reported that patients with complications tended to be older, female, non-white, have non-blunt mechanism, higher ISS, and hypotension on arrival. Overall mortality was highest (19%) in the oldest (≥ 86 years old) and most severely injured (ISS ≥ 25) patients and the occurrence of any complication was an independent predictor of overall mortality in geriatric patients (OR 2.3; 95% CI 2.2–2.4) [349].

Moreover sarcopenia is the strongest predictor of out-of-hospital mortality among older adults who sustained a fall (HR 4.77) [443]. Early diagnosis of sarcopenia allows the detection of trauma patients who are at high risk for adverse events. In geriatric blunt trauma patients, sarcopenia was associated with increased in-hospital mortality (OR 1.61), had a higher risk of discharge to less favourable destinations (OR 1.42) and had an increased risk of prolonged hospitalization (HR 1.21) [444].

There is a need for palliative care education for many specialists that are often still reluctant to palliative care. The utilization of palliative care is very low in this subset of patients: only 35% of patients with severe trauma brain injury receive palliative care. The available data show that palliative care is associated with less intensity of care, higher quality of life at the end of life and shorter length of stay for survivors. Integration of palliative care in the management of severe trauma brain injury patients definitively improves quality of care without reducing survival [445,446,447,448]. In conclusions, the implementation of palliative medicine consultation in the decision-making process at the hospital admission or in the first 24–72 h for geriatric trauma patients improves outcomes, reduces in-hospital mortality, length of stay and improve communication with family members [443,444,445, 449].

Conclusions

By the time, with the improvements of quality of life and care, elderly trauma patients (≥ 65 years old) are increasing. Trauma in elderly people has high mortality. The WSES decided to provide guidelines focused on the management of this group of co-morbid and frail patients and based on available evidence and on experts’ opinion, to improve elderly trauma patients’ care and decrease their mortality. The management of elderly trauma patients requires knowledge and understanding of ageing physiology and a multidisciplinary approach. Ageing is correlated with frailty and frailty is a risk factor for mortality. Focused triage and early activation of tailored trauma protocols for elderly trauma patients can improve their resuscitation, according to their different physiology and response to trauma stress. Early involvement of palliative care teams and shared decision making in assessing elderly injured patients can decrease futility, improve communication, outcomes and quality of life. Finally, geriatric ICUs are needed to care for elderly trauma patients using a multidisciplinary approach.