Frimley Guidelines

Imaging in Older and or Frail Patients (Silver Trauma)
(65+years)

Key Point

  • A consensus approach to imaging by Radiology and Emergency Department teams
Version:2.0
Date Issued:16/10/2025
Review Date:01/10/2028
Key words:Trauma, older, silver, imaging, CT

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition. Print copies must be destroyed after use.

Abbreviations

APAnterior-posterior
CTComputed Tomography
CXRChest X-ray
DOACDirect Oral Anticoagulant
GCSGlasgow Coma Scale
PEPulmonary emobolism
RTCRoad traffic collision
WBCTWhole Body CT

Introduction

Older and frail patients present particular challenges in identification of injuries and careful clinical assessment is required. “Low-energy” mechanism of injuries such as a fall from standing in older and frail patients are more likely to lead to injury and “high energy” mechanisms of injury are more likely to lead to significant and possible life-threatening multi-system injury. Standard “abnormal” parameters of physiology that are used to define states of shock and cardiorespiratory distress are not always applicable to the elderly patient.

The recommendations in this document are based on the HECTOR manual, https://www.embeds.co.uk/wp-content/uploads/2019/10/Hector-manual.pdf

For patients at Frimley Park Hospital (part of the South West London and Surrey Trauma Network) this guideline should be read in conjunction with the Network guidance  https://swlstrauma.net/documents/trauma-imaging.pdf

A full trauma team should be activated for patients with haemodynamic instability/significant mechanism of injury/suspicion of bleeding in the absence of haemodynamic instability (lactate >2.5; base deficit >5). See the Silver Trauma triage tool for further details.

Quick Questions

QuestionImaging modality
? C-Spine injuryCT C-spine
Quick decision need for large pneumathoraces/large haemothoracesCXR
? multiple rib fractureCT
? Pelvic fracturePlain film first line but if appears normal and still high clinical suspicion do CT

Regarding CT, for elderly patients with injuries, CT can help identify subtle injuries (e.g., TP fractures, rib fractures) which may not warrant immediate intervention but could lead to uncontrolled pain and the onset of delirium after admission.

It is important to take a rational approach to CT acquisition and not utilise a blanket approach of scanning every individual who presents with traumatic injuries.

Whole body CT scanning vs Focussed CT scanning

Whole Body CT Scanning (WBCT)

Vertex to pelvis/mid femoral region. Reserved for patients with suspected major injuries and major mechanism of injury. HECTOR advocates the following indications:

  • Obvious severe injury on clinical assessment, e.g., > 2 long limb fractures; pelvic fractures; amputation.

  • Haemodynamic instability or the presence of occult hypoperfusion with high mechanism of injury.

  • Suspicion of severe injury to more than one body region.

  • Significant mechanism of injury:

    • vehicular collision (i) ejection from vehicle, ii) entrapment in vehicle > 30 mins, iii) fatality at scene of vehicular collision, iv) high speed rollover

    • Fall from > 3M (10 foot)

    • Pedestrian hit by car

    • Fall down stairs

Focussed CT scanning


CT Head
Indication for CT head: Suspicion of traumatic injury +any of the following:

- GCS <13 on initial assessment

- GCS <15 after 2 hours of observation

- open or depressed skull fracture

- signs suggestive of basal skull fracture

- post-traumatic seizure

- focal neurological deficit

- >1 episode of vomiting

- loss of consciousness/amnesia (if 65 years or older)

- any patient on anticoagulant medication.

CT Cervical spine
NICE recommends CT for imaging if there is suspicion of injury in elderly patients following trauma.
https://www.nice.org.uk/guidance/ng41/chapter/recommendations

CT Chest NON-CONTRAST

(Request lower ribs
to be included on scan)
- suspected bony injury including multiple rib fractures +/ flail segments, e.g., fall whereby the chest wall has made contact with a hard object and the patient has on-going pain and difficulty in breathing. This will aid decision making about indications for epidural analgesia.

If there is no suspicion of great vessel injury, no suspicion of arterial injury and not history of penetrating trauma, a non-contrast CT scan will be appropriate to detect pulmonary contusions, haemopneumothoraces and bony injury.

CT chest CONTRAST ENHANCED
- suspicion of PE precipitating a fall

- suspicion of mediastinal injury

- suspicion of great vessel injury

- penetrating trauma

CT Abdomen and Pelvis
Isolated contrast enhanced CT abdomen and pelvis for identifying solid organ or bowel injury. Patients on warfarin or DOAC with blunt abdominal trauma are particularly susceptible to significant injury (e.g., retroperitoneal bleeding, soft tissue bleeding) so the threshold for scanning such patients should be lowered; low threshold for CT scanning in the presence of abdominal/back pain for any patient on warfarin or anticoagulants.

CT Pelvis NON-CONTRAST
if pelvic plain film normal but continued pain in pelvic area/unable to weight bear, to identify if any fracture is present.

CT Pelvis CONTRAST ENHANCED
patient with pubic rami fractures with persistent hypotension/falling Hb levels to identify the presence of local haematomas with active bleeding of vessels. Particularly relevant for patients on warfarin with these injuries.

Imaging of Thoracic and
Lumbar Spine
If suspicion of injury to the thoracic +/or lumbar spine, the most appropriate imaging modality will depend on mechanism of injury:

- High energy mechanisms such as falls from height/downstairs or high speed RTC (pedestrian vs car, rollover, ejection, death in same compartment, prolonged entrapment) are best imaged with WBCT or focussed CT.

- Patients with injury to thoracic cage and/or spine are best imaged using CT thorax.

- Patients who present following simple falls with thoracic spine or lumbar spine tenderness, (in isolation or combined), could be imaged using AP/lateral plain film radiography in the first instance. Any abnormality on plain film should warrant further CT/MRI imaging if the fractures look unstable and represent more than a simple osteoporotic crush injuries.