Geriatric trauma — occult shock, anticoagulation and frailty

Misleading vitals (4 marks). Beta-blockade blunts tachycardia so HR 68 does not exclude shock. Chronic hypertension means SBP ~110 may be relative hypotension. Occult hypoperfusion is revealed by lactate and base deficit. Brain atrophy allows large subdural volume before late deterioration. Ground-level falls can still produce major injury — mechanism alone undertriages.^[1]

Investigations (4 marks). Liberal CT head (anticoagulated, age, GCS less than 15) and low threshold for CT C-spine/chest for rib fractures. Coagulation panel; consider anti-Xa context; serial GCS. Rib fractures in elderly carry high mortality — count fractures, assess respiratory reserve.^[1][2]

Reversal, analgesia, disposition (4 marks). If intracranial bleeding on apixaban, reverse per local protocol (andexanet alfa where available / 4-factor PCC alternative) and involve neurosurgery/haematology.^[3] Multimodal analgesia and consider regional blocks; HDU for multiple rib fractures. Score Clinical Frailty Scale to guide intensity and goals; orthogeriatric/trauma admission rather than ED discharge.^[4]