De Simone et al. World Journal of
World Journal of Emergency Surgery (2024) 19:18
https://doi.org/10.1186/s13017-024-00537-8 Emergency Surgery
RESEARCH Open Access
The 2023 WSES guidelines
on the management of trauma in elderly
and frail patients
Belinda De Simone1,2,3*, Elie Chouillard3, Mauro Podda4, Nikolaos Pararas5, Gustavo de Carvalho Duarte6,
Paola Fugazzola7, Arianna Birindelli8, Federico Coccolini9, Andrea Polistena10, Maria Grazia Sibilla11,
Vitor Kruger12, Gustavo P. Fraga12, Giulia Montori13, Emanuele Russo14, Tadeja Pintar15, Luca Ansaloni6,
Nicola Avenia16, Salomone Di Saverio17, Ari Leppäniemi18, Andrea Lauretta19, Massimo Sartelli20,
Alessandro Puzziello21, Paolo Carcoforo11, Vanni Agnoletti14, Luca Bissoni14, Arda Isik22, Yoram Kluger23,
Ernest E. Moore24, Oreste Marco Romeo25, Fikri M. Abu‑Zidan26, Solomon Gurmu Beka27, Dieter G. Weber28,
Edward C. T. H. Tan29, Ciro Paolillo30, Yunfeng Cui31, Fernando Kim32, Edoardo Picetti33, Isidoro Di Carlo34,
Adriana Toro34, Gabriele Sganga35, Federica Sganga36, Mario Testini37, Giovanna Di Meo37,
Andrew W. Kirkpatrick38, Ingo Marzi39, Nicola déAngelis40, Michael Denis Kelly41, Imtiaz Wani42,
Boris Sakakushev43, Miklosh Bala44, Luigi Bonavina45, Joseph M. Galante46, Vishal G. Shelat47,
Lorenzo Cobianchi7,49, Francesca Dal Mas48,49, Manos Pikoulis4, Dimitrios Damaskos50, Raul Coimbra51,
Jugdeep Dhesi52, Melissa Red Hoffman53, Philip F. Stahel54, Ronald V. Maier55, Andrey Litvin56, Rifat Latifi57,58,
Walter L. Biffl59 and Fausto Catena60
Abstract
Background The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated
with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly
trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients
to improve it and reduce futile procedures.
Methods Six working groups of expert acute care and trauma surgeons reviewed extensively the literature accord‑
ing to the topic and the PICO question assigned. Statements and recommendations were assessed according
to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress
of the WSES in 2023.
Results The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage,
including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve out‑
comes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects
of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned
and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt
trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH
*Correspondence:
Belinda De Simone
Full list of author information is available at the end of the article
© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco
mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
,De Simone et al. World Journal of Emergency Surgery (2024) 19:18 Page 2 of 61
should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal
function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to dis‑
cuss the end of life in a multidisciplinary approach considering the patient’s directives, family feelings and representa‑
tives’ desires, and all decisions should be shared.
Conclusions The management of elderly trauma patients requires knowledge of ageing physiology, a focused tri‑
age based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care
Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality
and improve outcomes.
Keywords Elderly, Geriatric patient, Trauma management, Imaging, Laboratory test, Trauma score, Resuscitation,
Delirium, Pain control, Antibiotics, Thrombo-prophylaxis, Direct oral anticoagulants management, Vitamin K
antagonists anticoagulants management, Palliative care, End of life, Frailty, Ageing
Graphical abstract
The 2023 WSES guidelines on the management of trauma in elderly and frail patients.
The management of elderly trauma patients requires
BACKGROU D MAI TOPIC knowledge of ageing physiology, a focused triage, including
I VESTIGATED drug history, frailty assessment, nutritional status, and early
The trauma mortality activation of trauma protocol to improve outcomes.
rate is higher in the PRIMARY
elderly compared with EVALUATIO / Acute trauma pain in the elderly has to be managed in a
ASSESSME T multimodal analgesic approach, to avoid side effects of
younger patients. opioid use.
Ageing is associated with RESUSCITATIO Antibiotic prophylaxis is recommended in penetrating
physiological changes in (abdominal, thoracic) trauma, in severely burned and in
multiple systems and MA AGEME T OF open fractures in elderly patients to decrease septic
correlated with frailty. ORAL complications.
Frailty is a risk factor A TICOAGULA TS
Antibiotics are not recommended in blunt trauma in the
for mortality in elderly absence of signs of sepsis and septic shock.
trauma patients. A TIBIOTICS,
A ALGESIA A D A TI- Venous thromboembolism prophylaxis with LMWH or UFH
We aim to provide THROMBOTIC should be administrated as soon as possible in high and
evidence-based PROPHYLAXIS moderate-risk elderly trauma patients according to the renal
guidelines for the function, weight of the patient and bleeding risk.
management of geriatric MA AGEME T OF THE
trauma patients to E D-OF-LIFE I I A palliative care team should be involved as soon as possible
TRAUMA SETTI G FOR to discuss the end of life in a multidisciplinary approach
improve it and reduce
futile procedures. ELDERLY PATIE TS
representatives' desires. All decisions should be shared.
B.De Simone, F.Catena et al; WJES, 2024
Background group of “oldest old” patients, will increase to nearly 20
With improvements in health and social care in the last million persons by the year 2030 [1, 2].
century, the over-65-year-old patient cohort makes up In 2020, more than one-fifth (20.6%) of the EU popu-
a quarter of the population in the developed world. In lation was aged 65 and over [2].
the year 2000, the number of persons aged 65 years and The longer life expectancy of the world population,
older represented just more than 12% of the US pop- who adopt an active lifestyle, and the effect of aging on
ulation; by 2050, they are expected to make up more patients’ physiology sustain trauma and mortality. Age-
than 21% of the total population and almost 39% of related anatomical modifications such as decreased mus-
trauma admissions, with an increasing of more than cle mass and strength, bone density, and joint flexibility
20%. Patients aged 80 years and older that represent the and physiological changes, including decreased vision
,De Simone et al. World Journal of Emergency Surgery (2024) 19:18 Page 3 of 61
and hearing, slower reflexes, poorer balance, impaired disease, cancer, diabetes, or history of stroke [4 Grabo].
motor and cognitive function associated with unrecog- These comorbidities, when combined with frailty result
nised frailty, make caring for geriatric patients challeng- in more vulnerability to stress.
ing [3, 4]. This is the raison why elderly trauma patients cannot
Trauma is the fifth leading cause of death when all age be managed like adult younger trauma victims [18]. Deep
groups are considered, the fourth leading cause of death understanding of their physiology is essential to pro-
in those aged 55–64 years and the ninth leading cause of vide them with proper treatment [20]. Important issues
mortality in patients aged 65 years and older [4–6]. in improving the management and clinical outcomes of
The most common mechanism of injury in patients geriatric trauma include: (1) avoiding under-triage; (2)
aged ≥ 65 is the ground-level fall. Six percent of ground- early, targeted, and aggressive care; and (3) early admis-
level falls patients will sustain a fracture, and 10–30% of sion to an Intensive Care Unit (ICU). To accomplish
these patients will have polytrauma, being elderly people these points, we need to early assess and manage “frail”
more likely to sustain fractures of the cervical spine, ribs, patients. We aim to provide evidence-based guidelines
hip, and extremities. Mortality rate in this age-group is for the management of geriatric trauma patients so as to
reported to be as high as 7% [7–12]. Prevention strate- improve it and reduce futile procedures.
gies, endorsed recently by several western countries,
to reduce falls in elderly such as home-based exercise Methodology
programs and home safety interventions are effective to According to PICO [21] criteria, the coordinator of the
reduce the risk of falling but they have limited applica- project identified research areas, main topics and ques-
tions in active and independent people in the immediate tions correlated to geriatric trauma management to
future because of their high costs for healthcare systems investigate. The main topics and PICO questions are
[10]. summarized in the Table 1.
Motor vehicle crashes are the second most common Six working groups of experienced acute care and
mechanism of injury among older patients, and the most emergency surgeons were constituted to carry out a
common cause of traumatic mortality [4–7]. About one- focused systematic review about the topic assigned, using
quarter of all older adult victims of motor vehicle crashes PubMed, EMBASE, Google Scholar, and the Cochrane
sustain a chest injury which can exacerbate preexisting Central Register of Controlled Trials databases. accord-
cardiopulmonary disease and increases the risk of signifi- ing to PRISMA methodology [22]. Literature search was
cant complications, including pneumonia and respiratory concluded in May 2023, limited to articles in English
failure [4–6]. language and focused on the analysis of previously pub-
Older adults are second only to children as victims of lished systematic reviews with/without meta-analysis,
pedestrian injuries, but account for the largest percent- randomized controlled trials, and observational stud-
age of the auto-pedestrian fatalities. The highest mortal- ies (retrospective, prospective, and registry studies). The
ity rate in geriatric trauma is among pedestrians struck coordinator supervised each step of literature searching,
by a vehicle [7, 11–13]. study selection, the final presentation of evidence and
Elderly women are also at high risk of burn injury, wrote the manuscript.
mainly due to home accidents, caused mostly by fire Each working group provided a focused draft and a
and scalding [3, 14]. Burns can have a devastating effect variable number of statements and recommendations
on geriatric patients, in whom mortality is significantly according to the Grading of Recommendations, Assess-
higher than in younger adults for any size and localiza- ment, Development and Evaluation (GRADE) [23]. The
tion burn [15]. provisional statements and the supporting literature were
Geriatric patients are especially vulnerable to assault reviewed and discussed by email/call conferences and
(the fourth most common mechanism of injury), result- modified if necessary. Controversies statements and rec-
ing in 10% of geriatric trauma admissions. Geriatric vic- ommendations were validated with a Delphi consensus of
tims of violence are 5 times more likely to die compared WSES experts [24].
with younger victims [7, 11, 12]. The final manuscript was discussed during the WSES
Geriatric trauma mortality is high because of preex- Congress held in Pisa in June, 2023. Comments and sug-
isting medical conditions, frailty and poor physiological gestions were implemented to improve the recommenda-
reserve in elderly victims [16–19]. Eighty percent of geri- tions in the geriatric trauma management.
atric trauma patients have at least one chronic disease, The recommendations are summarised in Table 2.
such as hypertension, arthritis, heart disease, pulmonary
, De Simone et al. World Journal of Emergency Surgery (2024) 19:18 Page 4 of 61
Table 1 Topics and PICO questions
MAIN TOPIC PICO QUESTIONS
DEFINITIONS Q.1.1: Which trauma patient is defined as “old” at initial evaluation?
Q 1.2: When a patient is considered “physiologically old” and does he/she deserve
different management after (blunt and penetrating) trauma?
PRIMARY EVALUATION/ASSESSMENT Q 2.1:
Which injury (physiological and anatomical) scores are higher predictive of outcome
in evaluating elderly patients for trauma?
Q 2.2:
Which clinical features do better define the hemodynamic instability in geriatric
trauma patients?
Q 2.3:
Which laboratory tests and biological markers are useful to evaluate the elderly
trauma patient before resuscitation?
Q 2.4:
Which imaging studies are useful to better evaluate trauma elderly patients?
RESUSCITATION Q 3.1:
What early resuscitative protocol including intravenous fluids, blood transfusions
or vasopressors should be used to manage geriatric trauma patients at primary
evaluation?
Q 3.2:
Which are the resuscitation endpoints in elderly trauma patients?
Q 3.3:
Which vasopressors are indicated in comorbid elderly injured patients?
Q 3.4:
Vasopressors treatments versus permissive hypotension in geriatric trauma patients:
which are the clinical parameters and laboratory tests to consider in the choice?
Q 3.5:
How intraoperative hypotension status is correlated with delirium in geriatric
patients?
MANAGEMENT OF ORAL ANTICOAGULANTS Q 4.1:
Which blood tests are useful to evaluate geriatric patients with anticoagulant drugs
in trauma setting?
Q 4.2:
Which reversal protocol is indicated in patients in treatment with vitamin K antago‑
nists?
Q 4.3:
Which reversal protocol is indicated in patients in treatment with direct oral antico‑
agulants (DOACs) ?
ANTIBIOTICS, ANALGESIA AND ANTI-THROMBOTIC PROPHYLAXIS Q 5.1:
When is it indicated to administer antibiotics in elderly trauma patients?
Q 5.2:
How to control pain in elderly patients admitted for trauma?
Q 5.3:
When and how is indicated to perform thrombo-prophylaxis in elderly trauma
patients?
MANAGEMENT OF THE END-OF-LIFE IN IN TRAUMA SETTING Q 6.1:
FOR ELDERLY PATIENTS Which are the clinical features and vital parameters to define the elderly patient
at end of life after trauma?
Q 6.2:
Could palliative management be useful in the management of an elderly patient
at the end of life?
Notes on the use of these guidelines a standard of practice but a suggested plan of care,
The 2023 WSES geriatric trauma guidelines are the result based on the best available evidence and the consensus
of an extensive review of the literature and a validation of experts, but they do not exclude other approaches as
by a consensus of experts in the field. The statements and being within the standard of practice. These guidelines
recommendations provided in this work do not represent should be used and tailored by the treating surgeons and
World Journal of Emergency Surgery (2024) 19:18
https://doi.org/10.1186/s13017-024-00537-8 Emergency Surgery
RESEARCH Open Access
The 2023 WSES guidelines
on the management of trauma in elderly
and frail patients
Belinda De Simone1,2,3*, Elie Chouillard3, Mauro Podda4, Nikolaos Pararas5, Gustavo de Carvalho Duarte6,
Paola Fugazzola7, Arianna Birindelli8, Federico Coccolini9, Andrea Polistena10, Maria Grazia Sibilla11,
Vitor Kruger12, Gustavo P. Fraga12, Giulia Montori13, Emanuele Russo14, Tadeja Pintar15, Luca Ansaloni6,
Nicola Avenia16, Salomone Di Saverio17, Ari Leppäniemi18, Andrea Lauretta19, Massimo Sartelli20,
Alessandro Puzziello21, Paolo Carcoforo11, Vanni Agnoletti14, Luca Bissoni14, Arda Isik22, Yoram Kluger23,
Ernest E. Moore24, Oreste Marco Romeo25, Fikri M. Abu‑Zidan26, Solomon Gurmu Beka27, Dieter G. Weber28,
Edward C. T. H. Tan29, Ciro Paolillo30, Yunfeng Cui31, Fernando Kim32, Edoardo Picetti33, Isidoro Di Carlo34,
Adriana Toro34, Gabriele Sganga35, Federica Sganga36, Mario Testini37, Giovanna Di Meo37,
Andrew W. Kirkpatrick38, Ingo Marzi39, Nicola déAngelis40, Michael Denis Kelly41, Imtiaz Wani42,
Boris Sakakushev43, Miklosh Bala44, Luigi Bonavina45, Joseph M. Galante46, Vishal G. Shelat47,
Lorenzo Cobianchi7,49, Francesca Dal Mas48,49, Manos Pikoulis4, Dimitrios Damaskos50, Raul Coimbra51,
Jugdeep Dhesi52, Melissa Red Hoffman53, Philip F. Stahel54, Ronald V. Maier55, Andrey Litvin56, Rifat Latifi57,58,
Walter L. Biffl59 and Fausto Catena60
Abstract
Background The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated
with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly
trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients
to improve it and reduce futile procedures.
Methods Six working groups of expert acute care and trauma surgeons reviewed extensively the literature accord‑
ing to the topic and the PICO question assigned. Statements and recommendations were assessed according
to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress
of the WSES in 2023.
Results The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage,
including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve out‑
comes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects
of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned
and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt
trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH
*Correspondence:
Belinda De Simone
Full list of author information is available at the end of the article
© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco
mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
,De Simone et al. World Journal of Emergency Surgery (2024) 19:18 Page 2 of 61
should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal
function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to dis‑
cuss the end of life in a multidisciplinary approach considering the patient’s directives, family feelings and representa‑
tives’ desires, and all decisions should be shared.
Conclusions The management of elderly trauma patients requires knowledge of ageing physiology, a focused tri‑
age based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care
Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality
and improve outcomes.
Keywords Elderly, Geriatric patient, Trauma management, Imaging, Laboratory test, Trauma score, Resuscitation,
Delirium, Pain control, Antibiotics, Thrombo-prophylaxis, Direct oral anticoagulants management, Vitamin K
antagonists anticoagulants management, Palliative care, End of life, Frailty, Ageing
Graphical abstract
The 2023 WSES guidelines on the management of trauma in elderly and frail patients.
The management of elderly trauma patients requires
BACKGROU D MAI TOPIC knowledge of ageing physiology, a focused triage, including
I VESTIGATED drug history, frailty assessment, nutritional status, and early
The trauma mortality activation of trauma protocol to improve outcomes.
rate is higher in the PRIMARY
elderly compared with EVALUATIO / Acute trauma pain in the elderly has to be managed in a
ASSESSME T multimodal analgesic approach, to avoid side effects of
younger patients. opioid use.
Ageing is associated with RESUSCITATIO Antibiotic prophylaxis is recommended in penetrating
physiological changes in (abdominal, thoracic) trauma, in severely burned and in
multiple systems and MA AGEME T OF open fractures in elderly patients to decrease septic
correlated with frailty. ORAL complications.
Frailty is a risk factor A TICOAGULA TS
Antibiotics are not recommended in blunt trauma in the
for mortality in elderly absence of signs of sepsis and septic shock.
trauma patients. A TIBIOTICS,
A ALGESIA A D A TI- Venous thromboembolism prophylaxis with LMWH or UFH
We aim to provide THROMBOTIC should be administrated as soon as possible in high and
evidence-based PROPHYLAXIS moderate-risk elderly trauma patients according to the renal
guidelines for the function, weight of the patient and bleeding risk.
management of geriatric MA AGEME T OF THE
trauma patients to E D-OF-LIFE I I A palliative care team should be involved as soon as possible
TRAUMA SETTI G FOR to discuss the end of life in a multidisciplinary approach
improve it and reduce
futile procedures. ELDERLY PATIE TS
representatives' desires. All decisions should be shared.
B.De Simone, F.Catena et al; WJES, 2024
Background group of “oldest old” patients, will increase to nearly 20
With improvements in health and social care in the last million persons by the year 2030 [1, 2].
century, the over-65-year-old patient cohort makes up In 2020, more than one-fifth (20.6%) of the EU popu-
a quarter of the population in the developed world. In lation was aged 65 and over [2].
the year 2000, the number of persons aged 65 years and The longer life expectancy of the world population,
older represented just more than 12% of the US pop- who adopt an active lifestyle, and the effect of aging on
ulation; by 2050, they are expected to make up more patients’ physiology sustain trauma and mortality. Age-
than 21% of the total population and almost 39% of related anatomical modifications such as decreased mus-
trauma admissions, with an increasing of more than cle mass and strength, bone density, and joint flexibility
20%. Patients aged 80 years and older that represent the and physiological changes, including decreased vision
,De Simone et al. World Journal of Emergency Surgery (2024) 19:18 Page 3 of 61
and hearing, slower reflexes, poorer balance, impaired disease, cancer, diabetes, or history of stroke [4 Grabo].
motor and cognitive function associated with unrecog- These comorbidities, when combined with frailty result
nised frailty, make caring for geriatric patients challeng- in more vulnerability to stress.
ing [3, 4]. This is the raison why elderly trauma patients cannot
Trauma is the fifth leading cause of death when all age be managed like adult younger trauma victims [18]. Deep
groups are considered, the fourth leading cause of death understanding of their physiology is essential to pro-
in those aged 55–64 years and the ninth leading cause of vide them with proper treatment [20]. Important issues
mortality in patients aged 65 years and older [4–6]. in improving the management and clinical outcomes of
The most common mechanism of injury in patients geriatric trauma include: (1) avoiding under-triage; (2)
aged ≥ 65 is the ground-level fall. Six percent of ground- early, targeted, and aggressive care; and (3) early admis-
level falls patients will sustain a fracture, and 10–30% of sion to an Intensive Care Unit (ICU). To accomplish
these patients will have polytrauma, being elderly people these points, we need to early assess and manage “frail”
more likely to sustain fractures of the cervical spine, ribs, patients. We aim to provide evidence-based guidelines
hip, and extremities. Mortality rate in this age-group is for the management of geriatric trauma patients so as to
reported to be as high as 7% [7–12]. Prevention strate- improve it and reduce futile procedures.
gies, endorsed recently by several western countries,
to reduce falls in elderly such as home-based exercise Methodology
programs and home safety interventions are effective to According to PICO [21] criteria, the coordinator of the
reduce the risk of falling but they have limited applica- project identified research areas, main topics and ques-
tions in active and independent people in the immediate tions correlated to geriatric trauma management to
future because of their high costs for healthcare systems investigate. The main topics and PICO questions are
[10]. summarized in the Table 1.
Motor vehicle crashes are the second most common Six working groups of experienced acute care and
mechanism of injury among older patients, and the most emergency surgeons were constituted to carry out a
common cause of traumatic mortality [4–7]. About one- focused systematic review about the topic assigned, using
quarter of all older adult victims of motor vehicle crashes PubMed, EMBASE, Google Scholar, and the Cochrane
sustain a chest injury which can exacerbate preexisting Central Register of Controlled Trials databases. accord-
cardiopulmonary disease and increases the risk of signifi- ing to PRISMA methodology [22]. Literature search was
cant complications, including pneumonia and respiratory concluded in May 2023, limited to articles in English
failure [4–6]. language and focused on the analysis of previously pub-
Older adults are second only to children as victims of lished systematic reviews with/without meta-analysis,
pedestrian injuries, but account for the largest percent- randomized controlled trials, and observational stud-
age of the auto-pedestrian fatalities. The highest mortal- ies (retrospective, prospective, and registry studies). The
ity rate in geriatric trauma is among pedestrians struck coordinator supervised each step of literature searching,
by a vehicle [7, 11–13]. study selection, the final presentation of evidence and
Elderly women are also at high risk of burn injury, wrote the manuscript.
mainly due to home accidents, caused mostly by fire Each working group provided a focused draft and a
and scalding [3, 14]. Burns can have a devastating effect variable number of statements and recommendations
on geriatric patients, in whom mortality is significantly according to the Grading of Recommendations, Assess-
higher than in younger adults for any size and localiza- ment, Development and Evaluation (GRADE) [23]. The
tion burn [15]. provisional statements and the supporting literature were
Geriatric patients are especially vulnerable to assault reviewed and discussed by email/call conferences and
(the fourth most common mechanism of injury), result- modified if necessary. Controversies statements and rec-
ing in 10% of geriatric trauma admissions. Geriatric vic- ommendations were validated with a Delphi consensus of
tims of violence are 5 times more likely to die compared WSES experts [24].
with younger victims [7, 11, 12]. The final manuscript was discussed during the WSES
Geriatric trauma mortality is high because of preex- Congress held in Pisa in June, 2023. Comments and sug-
isting medical conditions, frailty and poor physiological gestions were implemented to improve the recommenda-
reserve in elderly victims [16–19]. Eighty percent of geri- tions in the geriatric trauma management.
atric trauma patients have at least one chronic disease, The recommendations are summarised in Table 2.
such as hypertension, arthritis, heart disease, pulmonary
, De Simone et al. World Journal of Emergency Surgery (2024) 19:18 Page 4 of 61
Table 1 Topics and PICO questions
MAIN TOPIC PICO QUESTIONS
DEFINITIONS Q.1.1: Which trauma patient is defined as “old” at initial evaluation?
Q 1.2: When a patient is considered “physiologically old” and does he/she deserve
different management after (blunt and penetrating) trauma?
PRIMARY EVALUATION/ASSESSMENT Q 2.1:
Which injury (physiological and anatomical) scores are higher predictive of outcome
in evaluating elderly patients for trauma?
Q 2.2:
Which clinical features do better define the hemodynamic instability in geriatric
trauma patients?
Q 2.3:
Which laboratory tests and biological markers are useful to evaluate the elderly
trauma patient before resuscitation?
Q 2.4:
Which imaging studies are useful to better evaluate trauma elderly patients?
RESUSCITATION Q 3.1:
What early resuscitative protocol including intravenous fluids, blood transfusions
or vasopressors should be used to manage geriatric trauma patients at primary
evaluation?
Q 3.2:
Which are the resuscitation endpoints in elderly trauma patients?
Q 3.3:
Which vasopressors are indicated in comorbid elderly injured patients?
Q 3.4:
Vasopressors treatments versus permissive hypotension in geriatric trauma patients:
which are the clinical parameters and laboratory tests to consider in the choice?
Q 3.5:
How intraoperative hypotension status is correlated with delirium in geriatric
patients?
MANAGEMENT OF ORAL ANTICOAGULANTS Q 4.1:
Which blood tests are useful to evaluate geriatric patients with anticoagulant drugs
in trauma setting?
Q 4.2:
Which reversal protocol is indicated in patients in treatment with vitamin K antago‑
nists?
Q 4.3:
Which reversal protocol is indicated in patients in treatment with direct oral antico‑
agulants (DOACs) ?
ANTIBIOTICS, ANALGESIA AND ANTI-THROMBOTIC PROPHYLAXIS Q 5.1:
When is it indicated to administer antibiotics in elderly trauma patients?
Q 5.2:
How to control pain in elderly patients admitted for trauma?
Q 5.3:
When and how is indicated to perform thrombo-prophylaxis in elderly trauma
patients?
MANAGEMENT OF THE END-OF-LIFE IN IN TRAUMA SETTING Q 6.1:
FOR ELDERLY PATIENTS Which are the clinical features and vital parameters to define the elderly patient
at end of life after trauma?
Q 6.2:
Could palliative management be useful in the management of an elderly patient
at the end of life?
Notes on the use of these guidelines a standard of practice but a suggested plan of care,
The 2023 WSES geriatric trauma guidelines are the result based on the best available evidence and the consensus
of an extensive review of the literature and a validation of experts, but they do not exclude other approaches as
by a consensus of experts in the field. The statements and being within the standard of practice. These guidelines
recommendations provided in this work do not represent should be used and tailored by the treating surgeons and
