# Falling Through the Cracks: A Look at Geriatric Trauma and Falls About This Webinar The Canadian Association of Emergency Physicians (CAEP) Geriatric Emergency Medicine Committee hosted this National Grand Rounds session on trauma and falls in older adults featuring Dr. Xavier Dubucs, Dr. Barbara Haas, and Dr. Christina Shenvi, and moderated by Dr. Isabelle Gray. Download Slide Deck https://youtu.be/MwfDjqsrkU4 Webinar Details Expert Panel Xavier Dubucs MD, PhD Emergency physician and clinical researcher at Toulouse University Hospital (France) and Université Laval (Quebec). Barbara Haas MD, PhD, FRCSC Trauma Medical Director at Sunnybrook (University of Toronto) and Scientist (Sunnybrook Research Institute). Christina Shenvi, MD, PhD, MBA, FACEP Emergency physician, educator and tenure professor at the University of North Carolina. Moderated By Isabelle Gray MD, MSc, FRCPC Hosted By Canadian Association of Emergency Physicians (CAEP)  Goals Apply current evidence for CT brain and C-spine imaging in older adults. Conduct a comprehensive falls assessment in the ED. Weigh the risks and benefits of C-spine immobilization. Integrate frailty into trauma assessment and decision-making. The Bottom Line Falls are the leading cause of traumatic injury in older adults, yet serious injuries may present with subtle findings. Careful clinical examination remains essential, even as age-specific decision tools emerge. Trauma centres provide substantial benefits beyond surgery alone, supporting recovery and functional outcomes long after the initial injury. Caring for older adult trauma patients requires both providers and systems to anticipate patient needs and provide coordinated care. Read More Below are highlights and take-home messages from each of the presentations.  Dr. Xavier Dubucs: Assessing Head Injury After a Fall + Dr. Dubucs reviewed emerging evidence on traumatic brain injury in older adults, emphasizing the continued importance of the clinical exam. Findings such as focal neurologic deficits, signs of skull fracture, altered mental status, and other concerning examination features remain among the strongest predictors of intracranial injury.[1] Anticoagulant or antiplatelet use alone appears to be a weaker predictor than traditionally assumed and should not replace sound clinical judgment.  For imaging decisions, the Canadian CT Head Rule and the NEXUS Rule remains the most extensively validated decision aids for minor head injury,  yet do not focus exclusively on older adults. Newer tools, such as the The Falls Decision Rule [2,3] and the recently derived PIWI rules[4] and may help identify low-risk patients who can safely avoid CT imaging.  Cervical spine injury remains an important consideration. Although prevalence is relatively low after minor falls, no dedicated, widely accepted decision rule exists for older adults. Clinical findings such as focal neurological deficits, midline cervical tenderness, and evidence of significant trauma should continue to guide imaging decisions.[5]   Dr. Barabara Haas: Trauma Care Beyond the Initial Injury+ Dr. Haas highlighted evidence from the EAST multicentre “Scanning the Aged to Minimize Missed Injury” study,[6] which demonstrated that injuries are common and frequently occult in older trauma patients. Findings support routine CT imaging of the head and cervical spine following significant trauma and consideration of additional torso imaging (“pan scan”) if any examination findings or high-risk features are present. Emergency physicians are encouraged to have a low threshold to discuss older adults with multi-system trauma with a trauma centre, especially those with severe injury (injury severity scores of 15 or more).[7] Trauma centres provide benefits extending well beyond operative care. They offer multidisciplinary teams to address acute injuries, mobility, rehabilitation, cognition, and discharge planning. Benefits are evident at 90 days and one year, speaking to the longer recovery period in this group. Importantly, older adults can have many quality years of life after a severe trauma and age alone is not a predictor. Dr. Christina Shenvi: Impact of ED Boarding on Older Adult Trauma Patients+ While older adult trauma patients often have medical complexities that potentially lead to injury and directly or indirectly impact recovery, Dr. Shenvi outlined how system function and capacity impact ED boarding. System factors worsens patient outcomes, provider burnout and system utilization. Upstream alternatives could prevent admission by strengthening post-ED visit follow up (such as next day home visits or ‘hospital at home’ models); strengthening pre-existing ties and utilization of community-based resources; and developing clear pathways for care and admission for patients with single system injuries. Older adult trauma patents incur iatrogenic harms as ED boarding lengthens. Pathways that reduce waits for older adults can mitigate some of the impact of long waits: prioritizing those at risk of delirium for a bed on the wards; vacating beds sooner by moving patients to a monitored “discharge lounge” while they await transport; establishing dedicated teams to care for patients who are boarded and implementing care pathways. Certain iatrogenic harms can be prevented by ED providers: encouraging early mobilization, diet orders, medication reconciliation, promoting sleep, reducing tethers (monitors, IV lines, foleys). Emergency physicians can play a key role in determining the trajectory of recovery among injured older adults. References Dubucs X, Gingras V, Boucher V et al. Risk Factors for Traumatic Intracranial Hemorrhage in Older Adults Sustaining a Head Injury in Ground-Level Falls: A Systematic Review and Meta-analysis. Ann Emerg Med. 2026 Feb;87(2):181-191. doi: 10.1016/j.annemergmed.2025.05.021. Epub 2025 Jul 22. PMID: 40699169.  de Wit K, Mercuri M, Clayton N, et al. Derivation of the Falls Decision Rule to exclude intracranial bleeding without head CT in older adults who have fallen. CMAJ. 2023;195:E1614-E1621.  Kudu E, Altun M, Danis F, et al. Validating the Falls Decision Rule: Optimizing head CT use in older adults with ground-level falls. CJEM. 2025.  Dubucs X et al. Risk stratification for significant acute traumatic intracranial hemorrhage in older adults after a ground-level fall. PLoS Med. 2026;23(8):e1004935.  Engelbart J, Zhou P, Johnson J, Lilienthal M, Zhou Y, Ten-Eyck P, Galet C, Skeete D. Geriatric clinical screening tool for cervical spine injury after ground-level falls. Emerg Med J. 2022 Apr;39(4):301-307. doi: 10.1136/emermed-2020-210693.  Ho VP, Kishawi SK, Hill H, et al. Scanning the aged to minimize missed injury: An EAST multicenter study. J Trauma Acute Care Surg. 2025;98(1):101-110.  De Simone B, Chouillard E, Podda M et al. The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World J Emerg Surg. 2024 May 31;19(1):18. doi: 10.1186/s13017-024-00537-8. PMID: 38816766; PMCID: PMC11140935.