The 2023 WSES guidelines on the management of trauma in elderly and frail patients
Authors: De Simone Belinda , Chouillard Elie , Podda Mauro , Pararas Nikolaos , de Carvalho Duarte Gustavo , Fugazzola Paola , Birindelli Arianna , Coccolini Federico , Polistena Andrea , Sibilla Maria Grazia , Kruger Vitor , Fraga Gustavo P. , Montori Giulia , Russo Emanuele , Pintar Tadeja , Ansaloni Luca , Avenia Nicola , Di Saverio Salomone , Leppäniemi Ari , Lauretta Andrea , Sartelli Massimo , Puzziello Alessandro , Carcoforo Paolo , Agnoletti Vanni , Bissoni Luca , Isik Arda , Kluger Yoram , Moore Ernest E. , Romeo Oreste Marco , Abu-Zidan Fikri M. , Beka Solomon Gurmu , Weber Dieter G. , Tan Edward C. T. H. , Paolillo Ciro , Cui Yunfeng , Kim Fernando , Picetti Edoardo , Di Carlo Isidoro , Toro Adriana , Sganga Gabriele , Sganga Federica , Testini Mario , Di Meo Giovanna , Kirkpatrick Andrew W. , Marzi Ingo , déAngelis Nicola , Kelly Michael Denis , Wani Imtiaz , Sakakushev Boris , Bala Miklosh , Bonavina Luigi , Galante Joseph M. , Shelat Vishal G. , Cobianchi Lorenzo , Mas Francesca Dal , Pikoulis Manos , Damaskos Dimitrios , Coimbra Raul , Dhesi Jugdeep , Hoffman Melissa Red , Stahel Philip F. , Maier Ronald V. , Litvin Andrey , Latifi Rifat , Biffl Walter L. , Catena Fausto 
Published: May 2024

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 according 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 outcomes. 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 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 discuss the end of life in a multidisciplinary approach considering the patient’s directives, family feelings and representatives' desires, and all decisions should be shared.

Conclusions
The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage 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.

Graphical abstract