Protocol

The rise in the number of elderly people living in the UK means an increasing number of trauma and
injuries in older people presenting at emergency rooms. Low-level falls are a leading cause of significant
injury in older people, and the numbers requiring emergency hospital treatment leading to hospitalisation
have increased.

Elderly patient care must be holistic and individualised regarding their treatment, its effect on their
wellbeing, and the likelihood of developing comorbidities such as dementia. Elderly major trauma patients
should not only receive the same care standards as any adult. They also require additional levels of
personalised care to avoid age bias. Age-based assumptions cause missed comorbidity risk identification,
from the effects of the injury itself, its treatment, and any changes to routines or needs their admission
causes.

Emergency department protocols should include specific elderly care elements for ED screening tools, admissions
and delirium advice, and other clinical guidelines include additional details specific to the treatment of frail
and elderly patients.

The Impact Of Age On The Presentation Of Trauma

Ageing, comorbid disease, an individual’s frailty and medications can all affect the physiological
presentation of major traumas in the elderly. Screening tools and patient and family questioning should be
carried out as early in patient care as possible to allow early injury identification, especially as many elderly
trauma patients do not present with an obviously significant mechanism. A trauma team present early in
the process, preferably recommended during the Emergency Department stage, will ensure a patient’s
assessment thoroughly questions and considers their pre-trauma state, current state and the risk of
secondary presentations, resulting either from the injury itself or ongoing treatment.

Emergency room post-fall protocols

Injury assessment on arrival should be a priority, and the trauma team assessment should include
knowledge to identify injury, complete resuscitation and manage immediate needs, followed by a
secondary survey.

Delirium is a risk to elderly patients suffering trauma from the injury itself and the stress and shock that the
injury causes. Carrying out a (HECTOR) Silver Survey as soon as possible will identify the patient’s risk of
developing delirium. Patients should then be assessed for comorbidity exacerbation and immediate
concomitant issues.

Actions should include a minimum of:
· A 12-lead ECG
· Blood tests
· Post postural blood pressure (when clinically appropriate)
· Chest X-ray
· Cognitive assessment
· A DNACPR, advanced directive review and patient wishes should be discussed with the patient
and family where necessary.
· Discussions and decisions on critical care suitability and premorbid function.

· Immediate consideration of timely anticoagulant reversal during the initial assessment
· Clinical, therapy and nursing assessments should consider pain using verbal and non-verbal
manifestations
· Obtain collateral history and review medications as soon as possible
· Therapists and specialised assessments early in the patient pathway
It is also recommended to avoid the use of urinary catheters unless medically essential in older patients.
They increase the patient’s risk of UTI, delirium and their associated need for lengthier hospital stays.

Before leaving the Emergency Department

The patient’s movement status should document the protection required for spinal and pelvic injuries and
be communicated to the ongoing care teams. Potential safeguarding issues should be addressed and
escalated accordingly in line with trust pathways if necessary.

Elderly patients arriving in the emergency department following a fall must be considered holistically and
individually relevant to their presentation. This will ensure a ‘one-size-fits-all age-bias and stereotyping
leading to a lack of early identification of comorbidities. Elderly patients are at a greater risk of shock, stress
and dementia through trauma, yet not all are the same, so understanding a patient’s normal’ is key to
noticing small or critical changes in their health.