# Older Adult Trauma Resident Handout (Age >=65)

**Primary objective:** prevent under-triage, delayed reversal, and failure-to-rescue.

## 1) Front-End Triage Triggers

- Geriatric shock trigger: SBP <110 mmHg OR HR >90 bpm.
- If trigger met: escalate trauma activation by one tier.
- Do not rely on HR alone (beta-blockers can mask tachycardia).

## 2) Arrival Algorithm (First Hours)

1. Standard ATLS + immediate medication reconciliation.
2. Obtain POC INR and/or anti-Xa when anticoagulation exposure is possible.
3. If head strike/mechanism concern or anticoagulated: mandatory CT head.
4. If ICH + anticoagulated: start reversal pathway immediately (target <=60 min from arrival).
5. Assign frailty (Rockwood CFS) within 24h using pre-injury baseline function.
6. If rib fractures: apply geriatric rib-fracture escalation thresholds.

## 3) Frailty-Guided Disposition (Rockwood CFS)

| CFS Group | Operational Pathway |
|---|---|
| 1-4 | Standard trauma pathway with early fall-risk and med review |
| 5-6 | Lower ICU threshold, delirium bundle, PT/OT day 1, social work screen |
| 7-8 | Early goals-of-care discussion, palliative consult, conservative escalation bias |
| 9 | Comfort-focused care discussion with patient/surrogate |

## 4) Delirium Prevention Bundle (Start on Admission)

- Sleep protection (night-time light/noise control, avoid overnight disruptions when possible).
- Medication discipline (avoid high-risk anticholinergic/benzodiazepine patterns when avoidable).
- Remove non-essential lines/tethers early.
- Early mobility + sensory optimization (hearing/vision aids).
- Reassess delirium/fall risk and med list at least q12h.

## 5) ICH + Anticoagulation Reversal (Target <=60 min)

| Agent Exposure | Recommended Reversal |
|---|---|
| Warfarin | 4F-PCC (INR based: 25/35/50 units/kg by INR bracket) + vitamin K 10 mg IV |
| Apixaban/Rivaroxaban | 4F-PCC 25-50 units/kg IV (starting at 25 units/kg may be appropriate in selected cases) |
| Dabigatran | Idarucizumab 5 g IV x1 |
| Antiplatelet-associated ICH | DDAVP 0.3 mcg/kg IV x1 (case-selected); avoid routine platelet transfusion unless neurosurgical indication |

### Reversal safety and follow-up
- Monitor for thrombosis after PCC.
- Resume VTE prophylaxis as soon as clinically appropriate per VTE protocol.
- Anticoagulation resumption after ICH is generally considered around 7-8 weeks (earlier in selected high-thrombotic-risk cases with multidisciplinary input).

## 6) Geriatric Rib Fracture Escalation

- Use CWITS-25-IS risk framework.
- If score >=4 (ward threshold), consider ICU for older adult.
- If score >=7, strongly consider early SSRF discussion.
- Aim for regional analgesia within 12 hours when feasible.

## 7) Hard Stops

- Do not under-triage SBP <110 as "stable" because it is not hypotensive by younger-adult criteria.
- Do not delay reversal while waiting for non-critical steps.
- Do not skip frailty scoring or delirium prevention in first 24h.
- Do not omit goals-of-care discussions in high-frailty trajectories.

## 8) PIPS Metrics

- Reversal speed for anticoagulated ICH: target <=60 min.
- Under-triage rate in geriatric shock phenotype: target <5%.
- Unplanned ICU transfer from floor in older adults: target <2%.

## Source Basis

Condensed from active older adult trauma guideline content (current revision pending formal approval, in active operational use).