Trauma: Silver Trauma in older patients

Related Subjects: |Initial Trauma Assessment and Management |Thoracic Trauma Assessment and Management |Flail Chest Rib fractures |Resuscitative Thoracotomy |Haemorrhage control |Traumatic Head/Brain Injury |Traumatic Cardiac Arrest |Abdominal trauma |Tranexamic Acid |Silver Trauma |Cauda Equina

⚠️ Silver Trauma: Major trauma in older adults (>65) is easily underestimated. Even “minor” mechanisms (e.g., fall <2m) can cause life-threatening injury. 👉 Always perform a full trauma assessment — missing occult injuries denies patients trauma team/specialist input.

👋 Introduction

• 🚶‍♂️ Falls from standing or <2m = most common mechanism.
• ❌ Often not recognised as “major trauma” ➝ patients miss trauma team activation.
• 📈 Older adults have higher mortality & morbidity than younger trauma patients.
• 🧠 Head injury & 🫁 chest trauma = leading causes of death.
• ⚡ Borderline physiology is significant: SBP <110 mmHg in >65s = same mortality risk as <90 in younger patients.

🛑 Mechanism of Injury (Red Flags)

• 🚪 Fall downstairs or from height (even modest).
• 🚲 Pedestrian or cyclist struck by vehicle.
• 🚗 RTC >30mph or significant mechanism.
• 🔪 Penetrating / crush torso injuries.
• 💥 Low-energy falls in anticoagulated patients ➝ high risk of intracranial bleed.

📊 Physiology & Injury Patterns

• ⚡ SBP <110 = shock until proven otherwise.
• ❤️ HR >90 may be only clue (beware β-blockers masking tachycardia).
• 🧠 GCS <15 → CT head regardless of mechanism.
• 🦴 ≥3 rib fractures ➝ pneumonia & respiratory failure risk.
• 📦 Multiple body regions often injured (polytrauma, not just one fracture).

💊 Medications Matter

• 💉 Anticoagulants (warfarin, DOACs, antiplatelets) ➝ ↑ risk of intracranial or occult bleed.
• 🩸 Pre-existing coagulopathy amplifies minor trauma into major bleeds.
• ⏰ Parkinson’s drugs: must be given on time to avoid decompensation.

🚨 Clinical Warnings

• 🕵️‍♂️ Occult shock: β-blockers, cardiac disease & dehydration mask typical signs.
• 🦴 Spinal fractures: Do not rely on Canadian C-spine rules ➝ low threshold for CT.
• ❓ Collapse vs trauma ➝ Did MI, arrhythmia, or stroke cause the fall?
• 👀 Secondary survey: avoid “tunnel vision” on the obvious fracture.
• 🧠 Low threshold for CT head ➝ chronic subdural haematoma common.

💥 Common Injuries in Silver Trauma & Their Management

Older adults sustain severe injuries from seemingly minor trauma. Always maintain a low threshold for imaging and specialist referral.

🧠 Head Injuries

• ⚡ Intracranial haemorrhage (esp. subdural) after minor falls.
• 💉 Anticoagulants/antiplatelets greatly increase risk.
• ❓ May present late (delayed deterioration, chronic SDH with confusion/falls).

Management: CT head for any confusion, GCS <15, or on anticoagulants. Neurosurgical referral if significant bleed. Reverse anticoagulation if appropriate.

🦴 Cervical Spine Injuries

• Fragile osteoporotic bone ➝ fractures even with low-energy falls.
• May have odontoid peg (C2) fractures, often missed on plain X-rays.
• 2nd fracture common ➝ always image whole spine if suspicious.

Management: CT cervical spine (not plain films). Immobilise until cleared. Consider neurosurgery/orthopaedics. Be cautious with collars (risk of pressure sores, delirium).

🫁 Chest Injuries

• ≥3 rib fractures ➝ high risk pneumonia, respiratory failure.
• Sternal fractures, flail chest, pulmonary contusions.
• Even 1–2 rib fractures can be life-threatening in frail elderly.

Management: Admit for monitoring, aggressive analgesia (nerve blocks, PCA, multimodal). Physiotherapy & chest physiotherapy. Low threshold for HDU/ICU referral if respiratory compromise.

🦵 Pelvic & Hip Injuries

• Fragility pelvic fractures ➝ massive haemorrhage risk even from falls at standing height.
• Hip fractures common ➝ huge mortality (30% at 1 year).
• Acetabular fractures more common in elderly than young.

Management: Early trauma CT if haemodynamic instability. Pelvic binder if unstable. Early ortho-geriatric involvement. Hip fractures ➝ analgesia, surgery if appropriate, bone protection, falls prevention.

🩸 Abdominal Injuries

• Solid organ injuries (spleen, liver) can occur even from low-energy trauma.
• May be occult – elderly compensate poorly and decompensate suddenly.

Management: Whole-body trauma CT. Serial bloods and monitoring. Consider IR (embolisation) rather than surgery in frail patients. Reverse anticoagulation.

🦴 Extremity Injuries

• Humerus, distal radius, and vertebral compression fractures very common.
• Often multiple concurrent fractures.
• Vertebral fractures ➝ pain, immobility, risk of delirium.

Management: Adequate analgesia, orthopaedic referral. Spinal brace if needed. Physiotherapy and early mobilisation essential.

🛠️ General Management Principles Across All Injuries

• 📸 Low threshold for CT scanning (head, C-spine, chest, abdomen/pelvis).
• 💊 Adequate analgesia, but beware oversedation (opioid-sparing where possible).
• 🩸 Reversal of anticoagulation if bleeding suspected/confirmed.
• 🛌 Prevent complications: delirium prevention, hydration, pressure sore care.
• 👨‍👩‍👦 Early TEP/DNACPR discussions in frail patients.
• 🛡️ Secondary prevention: bone health (DEXA, bisphosphonates, vitamin D), falls clinic referral.

📝 OSCE / Exam Pearls

• Always say: “Falls from standing can be major trauma in the elderly.”
• State SBP <110 is abnormal in >65s.
• Remember anticoagulants: always CT head even with minor mechanism.
• Distinguish collapse ➝ trauma vs trauma ➝ collapse.
• Mention TEP/DNACPR discussions in severe frailty.