Dear Editor,
We read with great interest the recent contribution by Koch et al. [1], which highlights the inadequacy of Trauma Team Activation (TTA) rates in geriatric trauma patients and their clinical implications. In older adults, even low-energy trauma can result in substantial morbidity and mortality, underscoring the critical importance of accurate and timely triage in this vulnerable group. Through its multicenter, prospective design and post-hoc analysis based on Trauma Team Activation and Trauma/Injury Care (TAcTIC) criteria, the study makes a valuable contribution to the literature by demonstrating a high under-triage rate of 53.8% in geriatric patients and its association with increased 48-hour mortality. However, we believe that clarification of several methodological and data presentation aspects could further strengthen the interpretative value and clinical applicability of the findings.
The study’s inclusion of only patients arriving at the emergency department within ≤ 6 h of injury may have resulted in the exclusion of delayed presentations, particularly among elderly individuals living alone or with limited social support. This scenario increases the risk of selection bias, potentially leading to underestimation of under-triage rates at the system level. If feasible, conducting subgroup analyses within this timeframe (e.g., 0–2 h vs. 2–6 h) and quantifying Emergency Medical Services calls (if any) that did not result in hospital transport would more clearly demonstrate the extent of this bias. The true rate of under-triage can only be determined by including patients who called emergency services but were not dispatched an ambulance or who were not evaluated and transported from the scene.
Moreover, delays in hospital admission in cases initially considered minor trauma can lead to irreversible delays in the diagnosis and treatment of time-critical complications, such as intracranial hemorrhage, massive bleeding from pelvic fractures, or sepsis. The authors should clarify whether any methodological measures were implemented in the study to mitigate this potential bias related to time to presentation, as such information would be highly informative for the design of similar future studies.
The severity of falls in the elderly population and the shifting sex distribution with age may directly impact the decision to conduct TTA. Literature indicates that low-energy trauma (e.g., falls at home) is more prevalent among female patients, whereas high-energy trauma (e.g., motor vehicle accidents, industrial injuries) is more common among younger males [2]. However, due to factors such as chronic disease, osteoporosis, anticoagulant/antiplatelet use, and diminished physiological reserve, even low-energy trauma in older patients can result in significant morbidity and mortality. Consequently, reporting under-triage rates according to mechanism of injury (e.g., low-energy fall vs. high-energy traffic accident) and sex could identify subgroups more likely to miss the TTA threshold, thereby informing the need to tailor triage criteria for these groups. For example, failure to initiate TTA in an elderly patient who develops severe intracranial hemorrhage or a pelvic fracture after a low-energy fall may substantially increase the risk of mortality due to delayed diagnosis and treatment.
Another potential reason for less aggressive treatment in geriatric patients may be drug–drug or drug–disease interactions resulting from regular medication use, combined with frequent comorbidities. These factors can lead to the avoidance of certain pharmacological agents and may limit treatment decisions, even in acute trauma. A comprehensive evaluation of the impact of such pharmacotherapeutic limitations on treatment preferences and patient prognosis could help optimize the management and assessment of geriatric trauma care. In addition, the study did not clearly specify which vital parameters were used to determine trauma team activation. Age-related changes in physiological response—such as beta-blocker–induced masking of tachycardia or hypoperfusion masked by normotensive readings—can reduce the sensitivity of standard triage criteria. Identifying which vital signs are most strongly associated with under-triage in geriatric patients would be invaluable, particularly for refining triage algorithms in this population.
We commend the authors for addressing such a clinically relevant topic. Incorporating the above clarifications, additional analyses, and subgroup stratifications could strengthen the clinical relevance of the findings and provide valuable methodological guidance for future research in geriatric trauma triage.
Yours sincerely,
Acknowledgements
None.
Abbreviations
- TAcTIC
Trauma Team Activation and Trauma/Injury Care
- TTA
Trauma Team Activation
Author contributions
M.S.H, E.T, and A.A wrote the main manuscript text. All authors reviewed the manuscript.
Funding
The author(s) received no financial support for this work, authorship, and/or publication.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Human rights
The principles set out in the Helsinki Declaration were followed. The need for informed consent was waived due to the retrospective nature of the study.
Competing interests
The authors declare no competing interests.
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References
- 1.Koch DA, Becker L, Schweigkofler U, Hagebusch P, Faul P, Waydhas C, et al. Undertriage in geriatric trauma: insights from a multicentre cohort study. Scand J Trauma Resusc Emerg Med. 2025;33(1):123. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Clare D, Zink KL. Geriatric trauma. Emerg Med Clin North Am. 2021;39(2):257–71. [DOI] [PubMed] [Google Scholar]
Associated Data
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Data Availability Statement
No datasets were generated or analysed during the current study.