Geriatric Trauma
Objective: Do not clear an older trauma patient because the crash was slow. Systolic pressure under 110 may already be shock. A normal-looking exam can miss brain bleeding, especially on a blood thinner.
Why this matters
A ground-level fall can look like a request only to help the patient up. ACS 2021 field-triage teaching says that in adults 65 and older, systolic blood pressure under 110 mm Hg may already be shock. Beta-blockers can hide the fast heart rate you expected. Anticoagulants can turn a scalp laceration into bleeding inside the skull. Do not send that patient to a hospital that cannot manage the injury. See also trauma triage.
- A systolic pressure of 118 can be a big drop for someone whose usual pressure is 160.
- Ask which blood thinner they take and when they were last at their baseline.
- A head strike plus an anticoagulant is time-critical even when the Glasgow Coma Scale (GCS) is 15.
- The mechanism can be "only a fall," and the patient can still have injuries that belong at a trauma center.
- Age 65 and older. Systolic pressure under about 110 may already be shock. Do not wait for 90.
- Which blood thinner? When were they last at baseline?
- Head strike plus a blood thinner. This is still a CT priority.
- A fall can still need a trauma center.
Why older adults are easy to miss
- Blood pressure: a "normal" systolic of 118 can be a drop from a baseline of 160. ACS 2021 lowered the hypotension threshold for age 65 and older. Under 110 may already be shock.
- Heart rate: beta-blockers and pacemakers can erase tachycardia. Do not require a fast heart rate before you believe the patient is in shock.
- Brain: age-related brain shrinkage, anticoagulants, and even a moderate mechanism can produce delayed bleeding inside the skull. Repeat the mental-status exam.
- Chest: rib fractures and a lung bruise can worsen over hours. Do not dismiss "only ribs."
- Bones: pelvic and hip fractures hide blood. Keep the pelvis on the shock list. Do not rock it. Use a binder only if your protocol still includes one (pelvic binder thinking).
Clinical sequence
- Use the same MARCH priorities: massive hemorrhage, airway, respirations, circulation, then hypothermia and head injury. Do not skip hemorrhage control because the patient looks fragile.
- Get the history: anticoagulants and antiplatelet drugs, POLST (physician orders for life-sustaining treatment) or other advance directives, baseline mental status, and when they were last well. Use those documents when they are on scene.
- Ask about pain and treat it per protocol. Older adults still hurt. Other drugs and slower clearance matter. Your protocol owns the milligrams. This site does not list a dose.
- Age, anticoagulation, pregnancy, and burns can still change destination even when the first vitals look acceptable. For age 65 and older, the shock teaching threshold is systolic pressure under 110 mm Hg, not 90.
- For spinal motion restriction, pad a kyphotic spine. That is the forward curve of the upper back that is common in older adults. A rigid board fits poorly and raises the risk of a pressure injury. Use a board for the move, then take the patient off it. See SMR.
- Keep the patient warm. Frail patients lose heat quickly.
Common errors
- Getting a blood pressure of 108 and calling the patient fine.
- Taking no anticoagulant history after a ground-level fall with a scalp hematoma.
- Going to the closest hospital because "it is only a fall."
Practice
One-minute check
An 82-year-old on apixaban fell from standing. GCS is 15, systolic pressure is 108, and there is a small scalp hematoma. Say what the pressure means, what kind of hospital you want, and one history item you will say on the radio.
Related: Trauma Triage, TBI, Syncope.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; your protocol decides
- ACS/CDC 2021 National Guideline for the Field Triage of Injured Patients — in adults ≥65 years, SBP <110 mm Hg may already represent shock; anticoagulation is a special consideration that can still change destination
- NAEMSP 2025 — Geriatric Trauma Patients — age-adjusted physiologic triage (SBP <110 teaching), treat pain, use POLST/advance directives when available, and do not force rigid SMR packaging onto a kyphotic neck
- Your state trauma plan may modify age and destination rules. Your protocol decides.
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.