. 2024 May 31;19:18. doi: 10.1186/s13017-024-00537-8

Table 2.

List of recommendations

PICO QUESTIONS	RECOMMENDATIONS
Q.1.1: Which trauma patient is defined as “old” at initial evaluation?	We suggest early trauma protocol activation in patients aged ≥ 55 years old [Weak recommendation based on a low level of evidence 2C] We recommend to carefully evaluate injured patients aged ≥ 55-year-old for potential high risk of mortality and to avoid under-triage [Strong recommendation based on a low level of evidence 1C]
Q 1.2: When a patient is considered “physiologically old” and does he/she deserve different management after (blunt and penetrating) trauma?	We suggest an early and rapid assessment of the patient including vital signs on presentation, mechanism of injury, injury severity and frailty including comorbidities and medication history to identify vulnerable trauma patients [Weak recommendation based on low level of evidence 2C] We recommend assessing frailty in all elderly trauma patients [Strong recommendation based on a moderate level of evidence 1B]
Q 2.1: Which injury (physiological and anatomical) scores are higher predictive of outcome in evaluating elderly patients for trauma?	We suggest evaluating elderly patients for trauma through the Geriatric Trauma Outcome Score (GTOS) to predict in-hospital mortality and the Trauma-Specific Frailty Index in order to identify patients at highest risk of poor outcome [Weak Recommendation, based on Moderate Quality of Evidence, 2B]
Q 2.2: Which clinical features do better define the hemodynamic instability in geriatric trauma patients?	We recommend keeping a lower threshold for trauma protocol activation in geriatric patients, with triage set points of heart ratio 90 bpm and systolic blood pressure less than 110 mmHg [Strong Recommendation, based on Moderate Quality of Evidence, 1B]
Q 2.3: Which laboratory tests and biological markers are useful to evaluate the elderly trauma patient before resuscitation?	We recommend performing an early blood gas (arterial or venous) for baseline base-deficit or a lactic acid assessment in geriatric trauma patients [Strong Recommendation, based on Moderate Quality of Evidence, 1B]
Q 2.4: Which imaging studies are useful to better evaluate trauma elderly patients?	We recommend a low threshold for initial imaging with CT scan in geriatric trauma patients. The diagnostic yield of a contrast-enhanced CT outweighs the risk of contrast-induced nephropathy, especially in view of the potential, dramatic effects of under-triage [Strong Recommendation, based on Moderate Quality of Evidence, 1B]
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?	We recommend that every trauma center provides meticulous triage criteria to recognize the need to early activate resuscitative protocols for elderly patients. These triaging criteria should include physical examination, vital signs, blood gas analysis, and medical history, emphasizing clinical conditions and drug history that may guide resuscitative therapies, early coagulative support, and the need to correct coagulopathies, and minimise fluids [Strong recommendation based on moderate quality of evidence 1B] We recommend rapid recognition and correction of coagulation disorders related to trauma or chronic medication intake in elderly patients. [Strong recommendation based on moderate quality of evidence 1B] We recommend performing serial base deficit assessment and lactate levels as markers of occult hypoperfusion in addition to close monitoring of vital parameters trend (heart rate, blood pressure, respiratory rate, urinary output), and mental status in elderly patients in a dedicated intensive geriatric care unit [Strong recommendation based on moderate-low level quality of evidence 1B] We suggest considering carefully to administer inotropic agents in selected non-responding elderly patients to target resuscitation [Weak recommendation based on low level of evidence 2C]
Q 3.2: Which are the resuscitation endpoints in elderly trauma patients?	We recommend evaluating the indication for invasive versus non-invasive hemodynamic monitoring on a case-by-case basis in injured elderly patients. Hypoperfusion should be ruled out by serial base deficit assessments and lactate concentration [Strong recommendation based on moderate-low level of evidence 1B] We suggest the implementation of POCUS in monitoring the cardiac function and blood volume in elderly injured patient, if skills are present. Invasive hemodynamic monitoring should be reserved in selected cases, to critically ill elderly trauma patients who have hypotension, significant injuries (as defined by an Abbreviated Injury Score > 3 or a Trauma Score < 15), or uncertain cardiovascular and/or fluid status [Weak recommendation based on moderate and low level of evidence 2B]
Q 3.3: Which vasopressors are indicated in comorbid elderly injured patients?	We recommend against the routine use of vasopressors in elderly injured patients presenting with hypotension caused by hemorrhage [Strong recommendation based on high-moderate level of evidence 1A] We recommend identifying the cause of hypoperfusion and assessing preexisting conditions and pharmacologic history before choosing a vasopressor in managing trauma in an elderly patient [Strong recommendation based on a high-low quality level of evidence 1A] We suggest using norepinephrine in elderly patients suffering from neurogenic shock. The dose to be used must be the lowest to guarantee tissue perfusion. The possible onset of cardiac arrhythmia and possible hypotensive effects should be monitored [Weak recommendation based on a moderate-low quality level of evidence 2B]
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?	We recommend to carefully evaluate to implement permissive hypotension in managing selected elderly trauma patients. Tissue perfusion has to be constantly monitored by base excess level, arterial lactates dosage, urine output, and when possible, neurologic assessment. [Strong recommendation based on a high-low quality level of evidence 1A]
Q 3.5: How intraoperative hypotension status is correlated with delirium in geriatric patients?	We suggest assessing, as early as possible, the risk factors for the onset of delirium because it is related to unfavourable outcomes in trauma geriatric patients. [Weak recommendation based on a moderate-low quality level of evidence 2B]
Q 4.1: Which blood tests are useful to evaluate geriatric patients with anticoagulant drugs in trauma setting?	We recommend performing routinely the common coagulation assays in elderly patients including the Activated Partial Thromboplastin Time (aPTT), Thromboplastin Time (TT), Prothrombin Time (PT), INR, and anti-Xa levels to assess early anticoagulants exposure in the trauma setting. There is not enough evidence to support the routinely use of TEG or ROTEM in elderly trauma patients. Further studies are necessary to determine their role. [Strong recommendation based on a moderate level quality of evidence 1B]
Q 4.2: Which reversal protocol is indicated in patients in treatment with vitamin K antagonists?	We recommend administrating a reversal agent in elderly trauma patients anticoagulated with oral vitamin K antagonists who present with bleeding, not responding to supportive measures, major life-threatening bleeding, bleeding located in critical organs (central nervous system, abdominal, thoracic), or needing urgent surgical or invasive procedures [Strong recommendation based on a moderate level quality of evidence 1B] We recommend using the reversal protocol including intravenous four factor prothrombin complex concentrates (4F-PCCs) and 5 mg intravenous vitamin K in case of life-threatening bleeding and/or urgent surgical procedures. Further doses should be administered if needed to achieve INR < 1.5 [Strong recommendation based on a high level quality of evidence 1A] We recommend giving Fresh frozen plasma (FFP) as oral vitamin K antagonists (VKAs) agent reversal only if no other treatment is available [Strong recommendation based on a moderate quality level of evidence 1B] We do not recommend the use of recombinant activated coagulation factor VII (rFVIIa) as first-line VKA reversal agent [Strong recommendation based on a low level of quality evidence 1C]
Q 4.3: Which reversal protocol is indicated in patients in treatment with direct oral anticoagulants (DOACs) ?	We recommend an early assessment of laboratory coagulation tests and direct measurements of DOAC levels, if quantitative tests are available, in elderly trauma patients receiving or suspected of having received a DOAC before deciding for reversal due to the thromboembolic risk [Strong recommendation based on a moderate level quality of evidence 1B] We suggest the administration of DOACS reversal agents only in critically ill patients with dosable plasma DOAC levels and presenting with hemorrhagic shock not responding to resuscitation, when level of DOACS can be assessed [Weak recommendation based on a moderate-low quality of evidence 2B] If the trauma patient with uncontrolled life-threatening bleeding, was treated with dabigatran (anti-FIIa activity), the suggested reversal protocol is to administer idarucizumab 5 g IV. If idarucizumab is not available, 50 units/kg IV of activated prothrombin complex concentrates (APCC) may be administrated [Weak recommendation based on a moderate-low quality level of evidence 2B] In patients with rivaroxaban-associated or apixaban-associated (FX inhibitors) life-threatening and uncontrolled bleeding, the suggested reversal protocol is the administration of andexanet alfa as an intravenous bolus of 400 mg over 15 min followed by a continuous infusion of 480 mg over 2 h (low dose) or 800 mg over 30 min followed by a continuous infusion of 960 mg over 2 h (high dose), according to the last dose of DOAC and the size of the dose. If andexanet alfa is not available, 2000 units of four-factor prothrombin complex concentrates (PCC) may be administrated [Weak recommendation based on a moderate-low quality level of evidence 2B]
Q 5.1: When is it indicated to administer antibiotics in elderly trauma patients?	We recommend antibiotic prophylaxis in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures in elderly patients to decrease septic complications [Strong recommendation based on a high-moderate quality level of evidence 1A] We recommend early empiric antibiotic therapy in patients presenting with signs of sepsis and septic shock and high risk patients (obesity, immunocompromised, high ASA score) in penetrating abdominal trauma, which should be active against common bacteria causing surgical site infections in peritonitis, such as Escherichia coli or other Enterobacteriales or Clostridiales [Strong recommendation based on a moderate quality level of evidence 1B] We recommend against the administration of antibiotics in blunt trauma in absence of signs of sepsis and septic shock [Strong recommendation based on a moderate-low quality level of evidence 1B]
Q 5.2: How to control pain in elderly patients admitted for trauma?	We recommend a regular administration of intravenous acetaminophen every 6 h as first line treatment in managing acute trauma pain in the elderly in a multimodal analgesic approach [Strong recommendation based on high quality level of evidence 1A] We suggest considering to add NSAIDs in elderly patients presenting with severe pain, taking into account potential adverse events and pharmacological interactions [Weak recommendation based on a moderate quality level of evidence 2B] We recommend the implementation of Multi-Modal-Analgesia approach (MMA) in trauma setting for elderly injured patients including acetaminophen, gabapentinoids, NSAIDs, lidocaine patches, and tramadol and opioids only for breakthrough pain for the shortest period of administration at the lowest effective dose [Strong recommendation based on a moderate quality level of evidence 1B] We recommend peripheral nerve blocks placement in elderly patients with acute hip fractures at the time of presentation to reduce preoperative and postoperative opioid use for analgesia [Strong recommendation based on a high quality level of evidence 1A] We suggest the adoption of epidural analgesia and regional anaesthesia to control severe pain in acute hip fractures in selected elderly patients [Weak recommendation based on a moderate quality level of evidence 2B] In elderly patients with ribs fractures, we recommend the association of systemic analgesic treatment with thoracic epidural and paravertebral blocks to offer an adequate pain control with limited contraindications and improvement in respiratory function, reducing opioid consumption, infections and delirium, if skills are available [Strong recommendation based on a high quality level of evidence 1A] We recommend to routinely consider the use of epidural or spinal analgesia for management of postoperative pain in elderly patients who undergo major thoracic and abdominal procedures for trauma, if skills are available [Strong recommendation based on a high-quality level of evidence 1A] We recommend carefully evaluating the use of neuraxial and plexus blocks for patients receiving anticoagulants to avoid bleeding and complications [Strong recommendation based on a high-quality level of evidence 1A] We suggest the implementation of non-pharmacological measures such as immobilizing limbs and applying dressings or ice packs in conjunction with drug therapy, in control acute pain in elderly patients in the trauma setting [Weak recommendation based on a very low level of evidence 2D]
Q 5.3: When and how is indicated to perform thrombo-prophylaxis in elderly trauma patients?	We recommend administering venous thromboembolism prophylaxis with LMWH or UFH as soon as possible in high and moderate risk elderly patients in the trauma setting according to the renal function, weight of the patient and bleeding risk [Strong recommendation based on a low quality level of evidence 1C] If pharmacological prophylaxis of venous thromboembolism is contraindicated, we recommend mechanical prophylaxis [Strong recommendation based on a low quality level of evidence 1C]
Q 6.1: Which are the clinical features and vital parameters to define the elderly patient at end of life after trauma?	We recommend discussing in a multidisciplinary approach the end of life in an elderly patient in the trauma setting. The decision should be considering the patient’s directives, family feelings and representatives desires and should be shared [Strong recommendation based on a low-very low quality of evidence 1D]
Q 6.2: Could palliative management be useful in the management of an elderly patient at the end of life?	We recommend involving as soon as possible the palliative care team in managing an elderly severely injured patient at the end-of-life status [Strong recommendation based on a low-very low quality level of evidence 1C]

PICO QUESTIONS

RECOMMENDATIONS

Q.1.1: Which trauma patient is defined as “old” at initial evaluation?

We suggest early trauma protocol activation in patients aged ≥ 55 years old [Weak recommendation based on a low level of evidence 2C]

We recommend to carefully evaluate injured patients aged ≥ 55-year-old for potential high risk of mortality and to avoid under-triage [Strong recommendation based on a low level of evidence 1C]

Q 1.2: When a patient is considered “physiologically old” and does he/she deserve different management after (blunt and penetrating) trauma?

We suggest an early and rapid assessment of the patient including vital signs on presentation, mechanism of injury, injury severity and frailty including comorbidities and medication history to identify vulnerable trauma patients [Weak recommendation based on low level of evidence 2C]

We recommend assessing frailty in all elderly trauma patients [Strong recommendation based on a moderate level of evidence 1B]

Q 2.1:

Which injury (physiological and anatomical) scores are higher predictive of outcome in evaluating elderly patients for trauma?

We suggest evaluating elderly patients for trauma through the Geriatric Trauma Outcome Score (GTOS) to predict in-hospital mortality and the Trauma-Specific Frailty Index in order to identify patients at highest risk of poor outcome [Weak Recommendation, based on Moderate Quality of Evidence, 2B]

Q 2.2:

Which clinical features do better define the hemodynamic instability in geriatric trauma patients?

We recommend keeping a lower threshold for trauma protocol activation in geriatric patients, with triage set points of heart ratio 90 bpm and systolic blood pressure less than 110 mmHg [Strong Recommendation, based on Moderate Quality of Evidence, 1B]

Q 2.3:

Which laboratory tests and biological markers are useful to evaluate the elderly trauma patient before resuscitation?

We recommend performing an early blood gas (arterial or venous) for baseline base-deficit or a lactic acid assessment in geriatric trauma patients [Strong Recommendation, based on Moderate Quality of Evidence, 1B]

Q 2.4:

Which imaging studies are useful to better evaluate trauma elderly patients?

We recommend a low threshold for initial imaging with CT scan in geriatric trauma patients. The diagnostic yield of a contrast-enhanced CT outweighs the risk of contrast-induced nephropathy, especially in view of the potential, dramatic effects of under-triage [Strong Recommendation, based on Moderate Quality of Evidence, 1B]

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?

We recommend that every trauma center provides meticulous triage criteria to recognize the need to early activate resuscitative protocols for elderly patients. These triaging criteria should include physical examination, vital signs, blood gas analysis, and medical history, emphasizing clinical conditions and drug history that may guide resuscitative therapies, early coagulative support, and the need to correct coagulopathies, and minimise fluids [Strong recommendation based on moderate quality of evidence 1B]

We recommend rapid recognition and correction of coagulation disorders related to trauma or chronic medication intake in elderly patients. [Strong recommendation based on moderate quality of evidence 1B]

We recommend performing serial base deficit assessment and lactate levels as markers of occult hypoperfusion in addition to close monitoring of vital parameters trend (heart rate, blood pressure, respiratory rate, urinary output), and mental status in elderly patients in a dedicated intensive geriatric care unit [Strong recommendation based on moderate-low level quality of evidence 1B]

We suggest considering carefully to administer inotropic agents in selected non-responding elderly patients to target resuscitation [Weak recommendation based on low level of evidence 2C]

Q 3.2:

Which are the resuscitation endpoints in elderly trauma patients?

We recommend evaluating the indication for invasive versus non-invasive hemodynamic monitoring on a case-by-case basis in injured elderly patients. Hypoperfusion should be ruled out by serial base deficit assessments and lactate concentration [Strong recommendation based on moderate-low level of evidence 1B]

We suggest the implementation of POCUS in monitoring the cardiac function and blood volume in elderly injured patient, if skills are present. Invasive hemodynamic monitoring should be reserved in selected cases, to critically ill elderly trauma patients who have hypotension, significant injuries (as defined by an Abbreviated Injury Score > 3 or a Trauma Score < 15), or uncertain cardiovascular and/or fluid status [Weak recommendation based on moderate and low level of evidence 2B]

Q 3.3:

Which vasopressors are indicated in comorbid elderly injured patients?

We recommend against the routine use of vasopressors in elderly injured patients presenting with hypotension caused by hemorrhage [Strong recommendation based on high-moderate level of evidence 1A]

We recommend identifying the cause of hypoperfusion and assessing preexisting conditions and pharmacologic history before choosing a vasopressor in managing trauma in an elderly patient [Strong recommendation based on a high-low quality level of evidence 1A]

We suggest using norepinephrine in elderly patients suffering from neurogenic shock. The dose to be used must be the lowest to guarantee tissue perfusion. The possible onset of cardiac arrhythmia and possible hypotensive effects should be monitored [Weak recommendation based on a moderate-low quality level of evidence 2B]

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?

We recommend to carefully evaluate to implement permissive hypotension in managing selected elderly trauma patients. Tissue perfusion has to be constantly monitored by base excess level, arterial lactates dosage, urine output, and when possible, neurologic assessment. [Strong recommendation based on a high-low quality level of evidence 1A]

Q 3.5:

How intraoperative hypotension status is correlated with delirium in geriatric patients?

We suggest assessing, as early as possible, the risk factors for the onset of delirium because it is related to unfavourable outcomes in trauma geriatric patients. [Weak recommendation based on a moderate-low quality level of evidence 2B]

Q 4.1:

Which blood tests are useful to evaluate geriatric patients with anticoagulant drugs in trauma setting?

We recommend performing routinely the common coagulation assays in elderly patients including the Activated Partial Thromboplastin Time (aPTT), Thromboplastin Time (TT), Prothrombin Time (PT), INR, and anti-Xa levels to assess early anticoagulants exposure in the trauma setting. There is not enough evidence to support the routinely use of TEG or ROTEM in elderly trauma patients. Further studies are necessary to determine their role. [Strong recommendation based on a moderate level quality of evidence 1B]

Q 4.2:

Which reversal protocol is indicated in patients in treatment with vitamin K antagonists?

We recommend administrating a reversal agent in elderly trauma patients anticoagulated with oral vitamin K antagonists who present with bleeding, not responding to supportive measures, major life-threatening bleeding, bleeding located in critical organs (central nervous system, abdominal, thoracic), or needing urgent surgical or invasive procedures [Strong recommendation based on a moderate level quality of evidence 1B]

We recommend using the reversal protocol including intravenous four factor prothrombin complex concentrates (4F-PCCs) and 5 mg intravenous vitamin K in case of life-threatening bleeding and/or urgent surgical procedures. Further doses should be administered if needed to achieve INR < 1.5 [Strong recommendation based on a high level quality of evidence 1A]

We recommend giving Fresh frozen plasma (FFP) as oral vitamin K antagonists (VKAs) agent reversal only if no other treatment is available [Strong recommendation based on a moderate quality level of evidence 1B]

We do not recommend the use of recombinant activated coagulation factor VII (rFVIIa) as first-line VKA reversal agent [Strong recommendation based on a low level of quality evidence 1C]

Q 4.3:

Which reversal protocol is indicated in patients in treatment with direct oral anticoagulants (DOACs) ?

We recommend an early assessment of laboratory coagulation tests and direct measurements of DOAC levels, if quantitative tests are available, in elderly trauma patients receiving or suspected of having received a DOAC before deciding for reversal due to the thromboembolic risk [Strong recommendation based on a moderate level quality of evidence 1B]

We suggest the administration of DOACS reversal agents only in critically ill patients with dosable plasma DOAC levels and presenting with hemorrhagic shock not responding to resuscitation, when level of DOACS can be assessed [Weak recommendation based on a moderate-low quality of evidence 2B]

If the trauma patient with uncontrolled life-threatening bleeding, was treated with dabigatran (anti-FIIa activity), the suggested reversal protocol is to administer idarucizumab 5 g IV. If idarucizumab is not available, 50 units/kg IV of activated prothrombin complex concentrates (APCC) may be administrated [Weak recommendation based on a moderate-low quality level of evidence 2B]

In patients with rivaroxaban-associated or apixaban-associated (FX inhibitors) life-threatening and uncontrolled bleeding, the suggested reversal protocol is the administration of andexanet alfa as an intravenous bolus of 400 mg over 15 min followed by a continuous infusion of 480 mg over 2 h (low dose) or 800 mg over 30 min followed by a continuous infusion of 960 mg over 2 h (high dose), according to the last dose of DOAC and the size of the dose. If andexanet alfa is not available, 2000 units of four-factor prothrombin complex concentrates (PCC) may be administrated [Weak recommendation based on a moderate-low quality level of evidence 2B]

Q 5.1:

When is it indicated to administer antibiotics in elderly trauma patients?

We recommend antibiotic prophylaxis in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures in elderly patients to decrease septic complications [Strong recommendation based on a high-moderate quality level of evidence 1A]

We recommend early empiric antibiotic therapy in patients presenting with signs of sepsis and septic shock and high risk patients (obesity, immunocompromised, high ASA score) in penetrating abdominal trauma, which should be active against common bacteria causing surgical site infections in peritonitis, such as Escherichia coli or other Enterobacteriales or Clostridiales [Strong recommendation based on a moderate quality level of evidence 1B]

We recommend against the administration of antibiotics in blunt trauma in absence of signs of sepsis and septic shock [Strong recommendation based on a moderate-low quality level of evidence 1B]

Q 5.2:

How to control pain in elderly patients admitted for trauma?

We recommend a regular administration of intravenous acetaminophen every 6 h as first line treatment in managing acute trauma pain in the elderly in a multimodal analgesic approach [Strong recommendation based on high quality level of evidence 1A]

We suggest considering to add NSAIDs in elderly patients presenting with severe pain, taking into account potential adverse events and pharmacological interactions [Weak recommendation based on a moderate quality level of evidence 2B]

We recommend the implementation of Multi-Modal-Analgesia approach (MMA) in trauma setting for elderly injured patients including acetaminophen, gabapentinoids, NSAIDs, lidocaine patches, and tramadol and opioids only for breakthrough pain for the shortest period of administration at the lowest effective dose [Strong recommendation based on a moderate quality level of evidence 1B]

We recommend peripheral nerve blocks placement in elderly patients with acute hip fractures at the time of presentation to reduce preoperative and postoperative opioid use for analgesia [Strong recommendation based on a high quality level of evidence 1A]

We suggest the adoption of epidural analgesia and regional anaesthesia to control severe pain in acute hip fractures in selected elderly patients [Weak recommendation based on a moderate quality level of evidence 2B]

In elderly patients with ribs fractures, we recommend the association of systemic analgesic treatment with thoracic epidural and paravertebral blocks to offer an adequate pain control with limited contraindications and improvement in respiratory function, reducing opioid consumption, infections and delirium, if skills are available [Strong recommendation based on a high quality level of evidence 1A]

We recommend to routinely consider the use of epidural or spinal analgesia for management of postoperative pain in elderly patients who undergo major thoracic and abdominal procedures for trauma, if skills are available [Strong recommendation based on a high-quality level of evidence 1A]

We recommend carefully evaluating the use of neuraxial and plexus blocks for patients receiving anticoagulants to avoid bleeding and complications [Strong recommendation based on a high-quality level of evidence 1A]

We suggest the implementation of non-pharmacological measures such as immobilizing limbs and applying dressings or ice packs in conjunction with drug therapy, in control acute pain in elderly patients in the trauma setting [Weak recommendation based on a very low level of evidence 2D]

Q 5.3:

When and how is indicated to perform thrombo-prophylaxis in elderly trauma patients?

We recommend administering venous thromboembolism prophylaxis with LMWH or UFH as soon as possible in high and moderate risk elderly patients in the trauma setting according to the renal function, weight of the patient and bleeding risk [Strong recommendation based on a low quality level of evidence 1C]

If pharmacological prophylaxis of venous thromboembolism is contraindicated, we recommend mechanical prophylaxis [Strong recommendation based on a low quality level of evidence 1C]

Q 6.1:

Which are the clinical features and vital parameters to define the elderly patient at end of life after trauma?

We recommend discussing in a multidisciplinary approach the end of life in an elderly patient in the trauma setting. The decision should be considering the patient’s directives, family feelings and representatives desires and should be shared [Strong recommendation based on a low-very low quality of evidence 1D]

Q 6.2:

Could palliative management be useful in the management of an elderly patient at the end of life?

We recommend involving as soon as possible the palliative care team in managing an elderly severely injured patient at the end-of-life status [Strong recommendation based on a low-very low quality level of evidence 1C]