For older adults after a fall from standing, GCS 8 or less was the predictor that mattered

Design

Retrospective multicentre registry cohort

Population

41 737 adults aged 65–89 with ground-level falls at 37 US level I/II trauma centres

Primary outcome

Receipt of ≥1 high-intensity time-sensitive intervention

Effect

GCS ≤8 aOR 42.3 (35.0–54.6); modelled over-triage 74.2% → 39%, under-triage 2.3% → 2.4%

This retrospective cohort used registry data from 41 737 adults aged 65 to 89 who presented after a ground-level fall to 37 US level I and II trauma centres. It asked what predicted the need for a high-intensity, time-sensitive intervention — the things a full trauma team exists to deliver.

A quarter received at least one such intervention. Full trauma activation was called for 5%, and 74.2% of those activations were over-triage. A GCS of 8 or less was the dominant predictor (adjusted OR 42.3, 35.0 to 54.6), carrying 58.4% of the model's explanatory power; age, comorbidity and anticoagulation contributed far less. Modelling a rule that restricted full activation to GCS 8 or less cut activations from 5.2% to 2.4% and over-triage from 74.2% to 39%, while under-triage was unchanged (2.3% vs 2.4%).

The finding supports keeping the full team for the obtunded older faller and managing the rest through a structured geriatric pathway: careful secondary survey, early CT head for those on anticoagulants, and senior review. It is a modelled strategy, not a tested one.

• Treat GCS 8 or less in an older faller as the strongest predictor of needing the full trauma team; a GCS-only activation rule looks promising but is untested.
• Age and anticoagulant use predicted the need for the full team far less than GCS; review how your protocol weights them before changing it.
• Still image the head early in anticoagulated older fallers, whatever their GCS.
• Perform a full secondary survey on every older faller; rib, pelvic and cervical spine injuries are easily missed.
• Review your own unit's over-triage rate for elderly falls before changing protocol.

Why it matters

Most full activations for elderly falls were unnecessary, and physiology — not age or anticoagulation — identified the patients who needed one.

Don't overread it

The GCS-only rule was modelled retrospectively on US data; it has not been tested prospectively.

The statistics, in plain English

Over-triage is the share of activations for patients who did not need the team; under-triage is the share of patients who needed it but did not get it. The modelled rule halved the first while the second moved from 2.3% to 2.4%, a change the P value (0.52) shows is compatible with chance.

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