Silver Trauma: Best Practice for Ax & Mx in the ED

 

Silver Trauma: Best Practice for Assessment and Management in the Emergency Department

Executive Summary

This document provides a comprehensive briefing on the assessment and management of "Silver Trauma"—significant injury in patients aged 65 and over. This patient demographic now constitutes the majority of major trauma cases in the UK, frequently presenting after low-energy falls (<2 metres). The core challenge lies in their diminished physiological reserve, multiple comorbidities, and polypharmacy, which blunt the typical signs of severe injury, leading to systemic under-triage, delayed diagnosis, and disproportionately high morbidity and mortality.

The fundamental principle of care is a shift from an injury-centric to a patient-centric, holistic model. Key best practices include mandatory triage modification with early senior clinician involvement, universal screening for frailty (Clinical Frailty Score) and delirium (4AT test), and the adoption of modified physiological thresholds for shock. A Systolic Blood Pressure < 110 mmHg, a Heart Rate > 90 bpm, or a venous lactate > 2.5 mmol/L are critical indicators of occult hypoperfusion requiring aggressive intervention.

Management requires a multidisciplinary team (MDT) approach initiated in the Emergency Department, incorporating geriatric principles into the standard trauma survey. This includes proactive management of geriatric syndromes (summarised by the PINCHME mnemonic: Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment), optimised analgesia with a focus on regional blocks, and a low threshold for comprehensive CT imaging. The use of structured screening tools, such as the 'Shake, Rattle, Rock and Roll' assessment, is advocated to detect occult truncal and head injuries. This integrated pathway aims to address the patient's intrinsic vulnerability concurrently with their acute injuries, thereby improving outcomes and ensuring they receive safe, high-quality, and dignified care.

1. Definition and Classification

Silver Trauma is a distinct clinical entity defined as significant injury or suspected major trauma occurring in patients aged 65 and over [1, 7]. Specific local guidelines may use a higher threshold of >70 years, or >65 years with a Rockwood Clinical Frailty Score (CFS) of ≥ 5 [39]. Others propose defining this group as those in their predicted last 10 years of life, which in Devon would be 75 years of age.

It is distinguished from trauma in younger cohorts by several key factors:

• Low-Energy Mechanisms: Seemingly minor mechanisms, such as a fall from standing height (<2 metres), are the most common cause of major injury (Injury Severity Score [ISS] >15) [8, 30, 40].
• Atypical Presentations: Age-related physiological changes, comorbidities (e.g., chronic hypertension), and polypharmacy (e.g., beta-blockers) blunt the classic physiological responses to trauma, masking signs of shock and severe injury [1, 8, 30]. Patients with chronic pain or cognitive decline may not present as expected, and the only clue to a fracture may be a loss of function, increased distress, or delirium.
• Holistic Nature: The patient's pre-injury state—including frailty, comorbidities, and cognitive function—is often a more significant determinant of outcome than the injury itself. Silver trauma is best conceptualised as a complex geriatric syndrome presenting with trauma [1, 9, 30, 41].

The core philosophy of management is to "treat patients with injuries and not injuries on patients" [41].

2. Epidemiology & Aetiology

• Incidence: Patients aged 65 and over are the fastest-growing demographic within the UK Major Trauma Network and represent the majority of major trauma patients [2, 30]. In one NHS trust, 70% of major trauma patients across specialities are aged 70 or over. These patients experience longer hospital lengths of stay and higher morbidity and mortality rates.
• Age and Frailty: Frailty is a superior predictor of outcomes than chronological age alone [12, 30]. The International Consortium on Health Outcome Measures defines older age as the last ten years of life before regional life expectancy, which may vary from 70 in parts of Northern England to 80 in parts of London [30].
• Aetiology: The most common mechanism of injury is a fall from standing height (<2m), which has surpassed road traffic collisions (RTCs) and accounts for the highest ISS and mortality rates [2, 8, 30, 40]. Venous tears are more common than visceral injury from low-energy mechanisms.
• Predisposing Factors: Declining proprioception and loss of protective reflexes lead to a higher rate of truncal injuries. Deconditioning leads to skeletal mineralisation loss. Assessment must extend beyond the injury to consider medical and social causes of the fall, including frailty, infection, cardiac events, neurological conditions, iatrogenic causes, neglect, and polypharmacy.
• Pathology and Injury Patterns: Skeletal and head injuries are the most common [8, 30]. Older people have a relative reduction in connective tissue in bone, meaning energy is not dissipated as effectively, leading to fractures from low-energy mechanisms.
  • Head Injuries: Intracranial haemorrhage (ICH) can be occult and well-compensated initially. A drop in GCS is often a later sign than in younger patients [41].
  • Truncal Injuries: The pattern is often determined by the fall mechanism:
    • Fall onto bottom (axial loading): Multi-level insufficiency fractures of the lumbar and thoracic spine.
    • Fall to side (hip and shoulder loading): Pubic rami and sacral alar fractures.
    • Fall forwards/backwards (head and C-spine loading): Intracranial haemorrhage and C-spine hyperflexion injuries [40].
  • Limb Injuries: Classic patterns include 'fall onto outstretched hand' (Colles' fracture) and ankle or hip fractures, with the knee usually preserved.

3. Pathophysiology and Clinically Relevant Anatomy

The ageing process involves the replacement of active parenchymal cells with inactive interstitial cells, leading to a loss of functional reserve and a decline in organ function [41]. This is a critical factor in the high morbidity and mortality observed in silver trauma [1, 4].

System	Age-Related Change	Clinical Implication in Trauma
Musculoskeletal	Osteoporosis and reduced bone mineral density. Degenerative changes (osteoarthritis, osteophytes) and conditions like Parkinsonism lead to rigidity and fixed flexion deformities.	Increased susceptibility to fractures from low-energy forces. Rigid structures (e.g., cervical spine) are more likely to fracture as they cannot absorb kinetic energy through flexion/extension [9, 41].
Respiratory	Increased chest wall rigidity, loss of respiratory muscle mass, reduced alveolar gas exchange surface area, and blunted central responses to hypoxia and hypercapnia.	Reduced compliance requires harder work for inspiration. Increased risk of fatigue and earlier onset of hypercapnic (Type II) respiratory failure, especially with chest wall injury. Simple rib fractures can have severe consequences [7, 41].
Cardiovascular	Myocardium replaced by collagen/fat, leading to stiffer ventricular walls and decreased cardiac reserve. Stiffening blood vessels, desensitised baroreceptors, and impaired autonomic function. Reduced atrial pacemaker cells lower resting and maximum heart rate. Atherosclerosis impairs organ blood flow.	Limited ability to increase cardiac output in response to shock. Blunted tachycardic response to hypovolaemia. Baseline hypertension means a "normal" BP (e.g., 120/80) may represent shock. Increased risk of severe organ injury with moderate hypotension [1, 6, 8, 41].
Neurological	Cerebral atrophy causes stretching and tautness of bridging subdural veins.	Increased risk of subdural haematoma from minor tearing forces after a fall. Increased intracranial space may delay symptoms, leading to a higher presenting GCS for a given injury severity [41, 44].

4. Clinical Assessment: Modified Trauma Survey

The standard CABCDE primary survey remains the foundation of care but requires significant modification to account for age-related changes and atypical presentations [15, 18, 41]. Senior clinician review (registrar or above) is triggered by the presence of high-risk features.

4.1. Catastrophic Haemorrhage

• Early Control: Identify and control overt bleeding immediately (e.g., scalp lacerations, epistaxis, long bone fractures) [41].
• Anticoagulation: Immediately identify anticoagulant and antiplatelet use. These patients are at high risk for catastrophic haemorrhage. Initiate reversal protocols early based on clinical suspicion, particularly with head injury, without waiting for laboratory confirmation [1, 6, 20, 28]. Administer Tranexamic Acid (TXA) to all bleeding trauma patients unless contraindicated [20, 21].

4.2. A Airway and Cervical Spine Control

• Airway Assessment: Be vigilant for obstruction from false teeth, friable tissue, and secretions. Weak respiratory muscles and a poor cough reflex increase risk [22, 28, 41]. Noisy breath sounds or paradoxical chest movements indicate obstruction [22]. Advanced airway management may be challenging due to obesity, altered dentition, and reduced neck movement (LEMON predictors) [18, 41].
• Cervical Spine Control:
  • Maintain a high index of suspicion for C-spine injury in any patient >65 with trauma to the head, face, or neck, or a high-energy mechanism [41]. Neck pain is a high-risk feature.
  • Minimal Movement Philosophy: Rigid collars are often poorly tolerated and may cause harm (pressure sores, increased ICP, aspiration). If a collar cannot be applied safely due to deformities (e.g., kyphosis), support the neck in its current position with rolled blankets or blocks [22, 41].
  • Clearance: CT is the imaging modality of choice for C-spine clearance in patients >65 [3, 41].

4.3. B Breathing and Ventilation

• Assessment: Record respiratory rate (RR), SpO2, and inspired O2. Rates >20 bpm may indicate distress, while <12 bpm can signify fatigue [22, 28]. Tachypnoea is often the first sign of developing shock.
• Key Injuries: Simple rib fractures can have grave consequences due to reduced physiological reserve [7, 28]. Maintain a low threshold for chest imaging.
• Oxygen Therapy: For major trauma, initially provide high-flow oxygen. For patients at risk of hypercapnic respiratory failure (e.g., severe COPD), target SpO2 of 88-92% once ABG results are available. Otherwise, target 94-98% [41].

4.4. C Circulation and Haemorrhage Control

• Recognising Shock: This is a primary failure point. The typical tachycardic response is often blunted or absent due to medications (beta-blockers, calcium channel blockers) or pacemakers.
  • Modified Vital Sign Thresholds: Act on subtle signs. A Systolic Blood Pressure < 110 mmHg or a Heart Rate > 90 bpm should be considered clinically significant and trigger aggressive resuscitation [1, 38, 40, 41, 42]. Some guidelines use a threshold of HR > 100 bpm.
  • A "normal" blood pressure of 120/80 may represent shock in a patient with baseline hypertension [8, 22, 28].
• Occult Hypoperfusion: Do not rely on vital signs alone. Routinely use objective markers:
  • A venous lactate > 2.5 mmol/L should be considered indicative of haemorrhage until proven otherwise [6, 38, 41, 42]. Some guidelines use a lower threshold of >2.0 mmol/L.
  • Base Excess (BE) is another critical marker [6].
• Haemorrhage Assessment: Examine for all potential bleeding sources. Use eFAST to "rule in" but not exclude significant injury [41]. Perform an Aortascan if a ruptured AAA is on the differential.
• Coagulopathy & Hypothermia:
  • Hypothermia Prevention: This is mandatory. Use warm blankets, Bair Huggers, and warmed IV fluids to maintain a core temperature between 36–37.4°C [19, 28, 41].
  • Fluid Resuscitation: Restrict crystalloid infusions. For haemorrhagic shock, activate the massive transfusion protocol and use blood products (e.g., 1:1:1 ratio) [41].

4.5. D Disability (Neurological Status)

• Neurological Assessment: Record GCS, pupil size, and reactivity. A GCS < 15 should not be assumed to be the patient's baseline without collateral history. Escalate immediately for new or worsening neurological signs [22].
• Cognitive and Delirium Screening:
  • This is a cornerstone of best practice. Any degree of cognitive impairment, acute or chronic, is a high-risk feature.
  • Screening Tools: The 4AT test is the recommended tool for delirium screening in all patients ≥65 [15, 16]. A score ≥4 indicates possible delirium/cognitive impairment [15]. The Abbreviated Mental Test Score (AMTS) should also be completed [22, 41].
  • Delirium Prevention & Management: Delirium is a medical emergency. Immediately implement delirium reduction strategies using the PINCHME mnemonic to address common causes [28, 41]:
    • Pain: Ensure adequate multimodal analgesia. Use the PAINAD scale for patients with cognitive impairment.
    • Infection: Screen for underlying infection (e.g., UTI, pneumonia).
    • Nutrition & Hydration: Provide food and fluids as soon as possible.
    • Constipation: Consider prophylactic laxatives with opiates. Check for urinary retention.
    • Hydration: (Covered under Nutrition & Hydration).
    • Medication: Conduct medicines reconciliation. Ensure time-critical drugs (e.g., for Parkinson's) are given on schedule.
    • Environment: Involve family, ensure patient is comfortable, and provide glasses and hearing aids.

4.6. E Exposure and Environment

• Hypothermia: Remove wet clothes and actively warm the patient [28, 41].
• Skin Integrity: Perform a full skin assessment, paying attention to pressure areas (occiput, sacrum, heels), especially under collars or splints [22, 41].
• Secondary and Tertiary Survey for Occult Injury: A formal head-to-toe secondary survey is mandatory. All falls, including ‘non-injury falls’, must be screened for trauma. Evidence of two or more injuries is a high-risk feature.
  • The ‘Shake, Rattle, Rock and Roll’ approach is advocated as a quick and reproducible screening assessment for occult injury in supine patients.
    • Shake: The patient is asked to actively shake their head. Asymmetric neck movement or pain should be assessed further. Then ask them to move both arms and legs, looking for pain.
    • Rattle: The patient is asked to take a deep breath in and cough. If pain-free, the chest is gently compressed anteriorly and bilaterally, screening for pain.
    • Rock: The pelvis is gently rocked bimanually at the iliac crests. This rotates the lumbar spine and loads the pelvis to unmask pain.
    • Roll: Gently roll each hip in turn (most easily done at the foot), then roll the patient on their side and palpate along the vertebrae.
  • A repeat tertiary survey, extending the assessment to 'Shake, Rattle, Rock and Roll with Stretch and Stroll', should be performed 24 hours after admission to re-review for missed or evolving injuries.

5. Key Investigations

5.1. Imaging

A low threshold for comprehensive imaging is crucial, as clinical examination is unreliable for excluding severe occult injuries [1, 24].

• Computed Tomography (CT):
  • Timing: Major trauma patients should have their CT scan started within 1 hour of arrival [24, 25]. Pre-existing renal disease should not delay a life-saving trauma CT scan [25].
  • Whole Body CT (WBCT): A "pan-scan" from vertex to pelvis is indicated for patients with high-energy mechanisms, haemodynamic instability, or suspicion of injury to more than one body region [28, 41].
  • Silver Trauma Pan-Scan: A modified non-contrast WBCT can be considered to reduce contrast load if there is no shock and a suspicion of multiple injuries [40]. If shock without an apparent cause is present, a contrast pan-scan is wise.
  • Focused CT:
    • Head: Recommended for any patient ≥65 with LOC or amnesia, or any patient on anticoagulants/antiplatelets after a head injury [3, 41, 42].
    • C-Spine: The imaging modality of choice for any patient ≥65 with suspected cervical spine injury [3, 28, 41]. A low threshold should exist for adding CT C-spine to a CT head scan.
• Plain Film Radiography: Has a limited role. C-spine X-rays have low sensitivity and are not recommended as first-line [3, 41]. Supine chest X-rays have low sensitivity for pneumothorax and rib fractures [41].
• Ultrasound:
  • eFAST: Should be used to "rule in" significant injury, not exclude it [41].
  • Chest Ultrasound: Superior to supine CXR for detecting pneumothorax [41].

5.2. Laboratory Investigations

• Arterial/Venous Blood Gas: Essential for assessing lactate, base excess, pH, PaO2, and PaCO2 to guide resuscitation [6, 41].
• Standard Trauma Bloods: Full blood count, urea & electrolytes, liver function tests, coagulation screen (including INR and fibrinogen), and Group & Save [41]. A haemoglobin drop of 15 g/L or more is a high-risk feature.
• Cardiac Markers: High-sensitivity troponin if an acute coronary syndrome is suspected as a precipitant for the fall [41].

6. Treatment and Management

6.1. The Holistic and Multidisciplinary Approach

Time-critical single-organ interventions are rarely required; the focus is on early comprehensive review and a holistic approach.

• Early MDT Involvement: Effective management requires an MDT approach commencing in the ED, including Emergency Medicine, Geriatrics (Care of the Elderly), Specialist Nursing, Pharmacy, Physiotherapy, and Occupational Therapy [8, 22].
• Comprehensive Geriatric Assessment (CGA): Geriatrician assessment is required within 72 hours for Major Trauma Centre admissions, but best practice dictates early involvement in the ED to guide care plans, cognitive assessment, and medication management [1, 9, 29].
• Patient-Centred Care: Adopt a ‘What matters most to you’ approach to focus on immediate patient goals, maintain motivation, and shape rehabilitation outcomes.
• Silver Trauma Admission Care Bundle: This framework ensures all aspects of holistic care are addressed:
  • Dignity, autonomy, and independence
  • Analgesia and Nausea Control
  • Bone protection
  • Collateral History
  • Constipation and Urinary Retention
  • Delirium Screen (and PINCHME)
  • Falls / Polypharmacy review (STOPP/START toolkit) [30, 41]
  • Fit to Sit and early mobilisation
  • Fluids, Blood products, and Anticoagulation management
  • Nutrition
  • OT & Physiotherapy review
  • Skin care / pressure areas
  • Treatment Escalation Plan (TEP)
  • Tertiary survey
  • VTE prophylaxis

6.2. Analgesia

Effective pain management is critical to prevent delirium and facilitate mobilisation [23].

Medication Class	Best Practice/Modification in Silver Trauma	Rationale
Acetaminophen	Consider reduced maximum daily dose for patients aged over 80 years.	Reduced drug clearance necessitates dose reduction [23].
Systemic Opioids	Fentanyl preferred initially. Use low starting doses and titrate slowly.	Minimises haemodynamic depression and CNS/respiratory side effects. Slower clearance of other opioids [23, 41].
Regional Analgesia	Mandate use of Ultrasound-Guided Nerve Blocks (UGNBs), e.g., Fascia Iliaca Block for hip/femur fractures.	Provides rapid, sustained, non-systemic pain relief; reduces opioid reliance and subsequent delirium risk [23, 27, 41].
NSAIDs	Use with extreme caution or avoid entirely.	High risk of renal and gastrointestinal injury [23, 41].
Skeletal Muscle Relaxants	Avoid entirely.	High anticholinergic effects increase the risk of delirium [23].

6.3. Management of Specific Injuries

• Head Injury: Management focuses on preventing secondary brain injury (avoiding hypoxia and hypotension). Prognosis is significantly worse with increasing age; early and honest discussions about goals of care are vital [41, 44].
• Fragility Fractures (e.g., #NOF): Require an integrated orthogeriatric care model with surgery within 36 hours [31, 41].
• Spinal Injuries: Conservative management with collars requires a careful risk/benefit assessment due to risks of pressure injury, aspiration, and delirium. Patients must not be nursed on dynamic pressure-reducing air mattresses [22].
• Rib Fractures: Require aggressive pain management (consider epidural for ≥4 fractures) and chest physiotherapy to prevent pneumonia [41, 43].

7. Complications

Vigilance for complications is essential, as deterioration can be rapid.

7.1. Complications of the Condition

Complication	Key Features & Management
Delirium	Common and serious. Prevent and manage by addressing PINCHME factors. Avoid ward moves where possible as this can worsen delirium [8, 30, 41].
Venous Thromboembolism (VTE)	High risk due to immobility. Requires risk assessment and appropriate prophylaxis [41].
Infection	High risk of hospital-acquired pneumonia and UTIs. Infection is a common precipitant for delirium [28, 41].
Autonomic Dysreflexia	Life-threatening emergency in spinal cord injury, often triggered by bladder/bowel distension. Presents with sudden hypertension and bradycardia [22].
Pressure Ulcers	High risk due to immobility, poor nutrition, and fragile skin. Requires vigilant skin care [22, 41].

7.2. Complications of Treatment

• Immobilisation: Prolonged bed rest or collar use increases the risk of delirium, VTE, pneumonia, aspiration, and pressure sores [22, 41].
• Pharmacological:
  • Opiates: Risk of respiratory depression, sedation, constipation, and delirium [41].
  • Benzodiazepines: Can cause prolonged sedation and increase delirium risk [41].
  • NSAIDs: Risk of acute kidney injury and GI bleeding [41].
• Catheterisation: Increases risk of UTI, which can trigger delirium. Remove as soon as no longer required [22].

References

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Appendix: Example Electronic Health Record (EHR) Documentation

Silver Trauma Assessment (.SILVERTRAUMA) ED Provider Note

TIME OF ASSESSMENT: PATIENT IDENTIFIERS: Name, DOB, Hosp No.

HISTORY OF PRESENTING COMPLAINT:

• Mechanism of Injury: [ ] Fall <2m (standing height), [ ] Fall >2m, [ ] Fall downstairs, [ ] RTC, [ ] Pedestrian vs. Vehicle, [ ] Other: ______
• Time of Injury: ______
• Loss of Consciousness: [ ] Yes, [ ] No, [ ] Unknown
• Amnesia: [ ] Yes, [ ] No, [ ] Unknown
• Pre-event symptoms: [ ] Dizziness, [ ] Chest Pain, [ ] Palpitations, [ ] SOB, [ ] Focal neurology, [ ] None reported
• Long lie suspected: [ ] Yes, [ ] No, [ ] Unknown

PAST MEDICAL HISTORY:

• [ ] Hypertension, [ ] IHD, [ ] Heart Failure, [ ] AF, [ ] CVA/TIA, [ ] COPD, [ ] Diabetes, [ ] CKD, [ ] Cancer, [ ] Dementia, [ ] Parkinson's Disease

MEDICATIONS:

• Anticoagulant/Antiplatelet: [ ] None, [ ] Warfarin (last INR: __), [ ] Apixaban, [ ] Rivaroxaban, [ ] Dabigatran, [ ] LMWH, [ ] Aspirin, [ ] Clopidogrel
• Rate/Rhythm Control: [ ] Beta-blocker, [ ] Calcium Channel Blocker, [ ] Digoxin
• Time-critical meds (e.g., Parkinson's) due: Yes/No, Time: _____

FUNCTIONAL & SOCIAL HISTORY:

• Accommodation: [ ] Own home, [ ] Sheltered, [ ] Residential/Nursing Home
• Pre-injury Mobility: [ ] Independent, [ ] Stick, [ ] Frame, [ ] Chairbound, [ ] Bedbound
• Clinical Frailty Score (CFS): ______ (1-9)
• Collateral history from: [ ] Family, [ ] Carer, [ ] Paramedics, [ ] Not available

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EXAMINATION (C-ABCDE Approach):

• Catastrophic Haemorrhage: [ ] None. [ ] Active, controlled.
• Airway: [ ] Patent and self-maintained. [ ] Concerns (e.g., secretions, stridor).
• C-Spine: [ ] No tenderness. [ ] Midline tenderness. [ ] Immobilised (Collar/Blocks/Minimal Movement).
• Breathing: RR: __, SpO2: __% on __ O2. [ ] Symmetrical chest expansion. [ ] No respiratory distress. [ ] Signs of distress/injury present.
• Circulation: HR: __, BP: /. [ ] Warm & well-perfused. [ ] Signs of shock (cool, clammy).
• Disability: GCS: E__V__M__ = __/15. Pupils: __mm, PERL. Blood Glucose: __. Gross neurology intact.
• Cognitive Screen: 4AT Score: ______ ([ ] Alert, [ ] AMT4: __/4, [ ] Attention test passed, [ ] Acute change/fluctuating course).
• Exposure: Temp: __°C. Full secondary survey performed.
• Injuries identified: ______________________

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INVESTIGATIONS:

• ECG: [ ] Sinus Rhythm. [ ] AF. [ ] Other: ______
• VBG/ABG: pH: __, Lac: __, BE: __, pCO2: __, pO2: __
• Bloods: Pending / Reviewed. Key results: Hb __, Plt __, INR __, Creatinine __
• Imaging Requested: [ ] CT Head, [ ] CT C-Spine, [ ] CT Chest/Abdo/Pelvis (Trauma Pan-Scan), [ ] X-Rays: _____
• Imaging Results: ______________________

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MEDICAL DECISION MAKING & PLAN: Impression: ___ year old patient with Silver Trauma secondary to ______. Key issues identified are ________________.

Problem Synthesis & Risk Assessment: The patient presents with significant injuries following a low-energy mechanism. The blunted physiological response (HR/BP) relative to their likely baseline and comorbidities suggests a high risk of occult injury and decompensation. Lactate is ___, indicating potential hypoperfusion. The CFS is ___, indicating significant frailty. The 4AT score of ___ suggests underlying cognitive impairment and/or acute delirium, which complicates assessment and increases risk of adverse outcomes. The patient is on ______ (anticoagulant), increasing haemorrhage risk.

Differential Diagnosis:

• Traumatic: Occult intracranial/thoracic/abdominal haemorrhage, further occult fractures.
• Medical Precipitant: ACS, arrhythmia, sepsis (UTI/Pneumonia), PE, stroke, hypoglycaemia, postural hypotension.

Plan:

1. Resuscitation: IV access established. Targeted fluid resuscitation based on lactate/BE. TXA administered. Anticoagulation reversal with ______ initiated. Active warming measures in place.
2. Analgesia: Multimodal approach. Regional block (e.g., FICB) performed for ______ fracture. Low-dose IV Fentanyl for breakthrough pain.
3. Investigations: Awaiting CT results. Serial VBG for lactate clearance.
4. Holistic/Geriatric Care:
   • Delirium Prevention (PINCHME): Pain managed. Infection screen sent (Urine/CXR). IV hydration commenced. Bowel/bladder plan initiated. Medication reconciliation in progress. Patient's glasses/hearing aids requested.
   • Treatment Escalation Plan (TEP): Discussion initiated regarding ceilings of care and resuscitation status.
5. Referrals & MDT Communication:
   • Admit under: [ ] Trauma & Orthopaedics, [ ] General Surgery, [ ] Acute Medicine
   • Referral to: Geriatrics (Care of the Elderly) for co-management and CGA. Pharmacy for medication review.
   • Disposition: For admission to ______ ward for ongoing care and MDT management. Critical care consultation if required.

Provider: _______________ GMC: _______ Date/Time: ________

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