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Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as yougive appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified thelicensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to thematerial. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation orexceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit. †P. Faul and P. Hagebusch contributed equally to this work. *Correspondence: P. Faul Full list of author information is available at the end of the article Abstract Background The 2022 revision of the German Trauma Society’s (DGU) trauma team activation (TTA) criteriaintroduces geriatric-specific modifiers to enhance the sensitivity of risk stratification in older (elderly) trauma patients.This study evaluates the validity of these updated criteria using national registry data, with particular focus onmortality gradients across activation levels and the prognostic value of newly incorporated modifiers. Methods We conducted a retrospective cohort analysis of patients aged ≥ 60 years, defined as elderly traumapatients, from the TraumaRegister DGU® (TR-DGU) between 2018 and 2023. Cases were stratified according to TTAstatus based on both the 2016 and 2022 DGU guidelines: high risk of severe injury (HRSI), moderate risk of severeinjury (MRSI), or None (provider decision). The primary outcome was in-hospital mortality. Subgroup analysesexamined the impact of pre-injury anticoagulation, systolic blood pressure (SBP) 91–100 mmHg, Glasgow Coma Scale(GCS) 13–14, and multiple serious injuries, defined as Abbreviated Injury Scale (AIS) ≥ 3 in two or more body regions. Results Among 66,273 elderly trauma patients, mortality according to the 2022 criteria showed a consistent riskgradient: 20.2% (high risk of severe injury, HRSI), 9.0% (moderate risk of severe injury, MRSI), and 4.2% (None). Incontrast, the 2016 criteria yielded inconsistent patterns, including higher mortality in the “None” category. Newmodifiers were strongly predictive of mortality: multiple serious injuries in ≥ 2 regions (16.7% vs. 6.7%), SBP 91–100mmHg (13.1% vs. 7.3%), and GCS 13–14 (12.5% vs. 5.6%). Pre-injury anticoagulation was associated with increasedmortality across all subgroups (29.3% vs. 20.3%). Conclusion The 2022 TTA criteria improve the alignment between triage criteria and observed mortality risk,particularly among elderly patients. The addition of geriatric-specific modifiers enhances predictive accuracy andclinical applicability. Future work should quantify implications for overtriage and resource allocation to supportevidence-based trauma system optimization. Validation of the 2022 German trauma teamactivation criteria: a national registry studywith focus on geriatric-specific modifiers P. Faul1*, P. Hagebusch1†, R. Lefering2, U. Schweigkofler1, M. Münzberg1, T. Jakobi1, D. A. Koch1 andthe Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the GermanTrauma Society (DGU) Faul et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine(2026) 34:103 [ ![http://crossmark.crossref.org/dialog/?doi=10.1186/s13049-026-01641-1&domain=pdf&date_stamp=2026-6-9]() ](http://crossmark.crossref.org/dialog/?doi=10.1186/s13049-026-01641-1&domain=pdf&date_stamp=2026-6-9) ![BioMed Central Logo]() ### Page 2 Introduction Trauma continues to impose an immense global healthburden, accounting for approximately 4.4 million injury-related deaths annually, equating to 8% of all global mor-tality []. In high-income settings, trauma often ranks asthe leading cause of death among individuals under 50years of age, with increasing contributions across elderlyage groups as populations age [,]. Rapid recognition and early mobilization of traumacare resources—commonly via TTA—are core tenetsof trauma care. TTA protocols typically combine physi-ological thresholds (e.g., hypotension, impaired con-sciousness), mechanism-of-injury criteria, and specialconsiderations like age or anticoagulation status [].However, overtriage (unnecessary activations) andundertriage (missed critical cases) persist as challengesworldwide, with undertriage rates in modern systemsreportedly ranging up to 20% []. Elderly trauma patients demonstrate distinct physiol-ogy—altered tachycardic response, impaired vascularreactivity, and frequent comorbidities—that often ren-der standard activation thresholds insensitive []. As aresult, undertriage in elderly trauma is substantial, withone recent German multicenter cohort revealing a 53.8%undertriage rate among patients ≥ 70 years of age, whodespite comparable severity, received TTA only 15.8% ofthe time (vs. 31.8% in younger groups), and experiencedmore than threefold higher early mortality (1.8% vs. 0.5%)[]. Another German registry study reported a 15.3%undertriage rate in severely injured elderly (median age80 vs. 55 years) []. The DGU has leveraged its TR-DGU and nationalTraumaNetzwerk to evaluate the real-world performanceof TTA criteria over time. Earlier versions of the GermanS3 Guideline on Treatment of Polytrauma and SeverelyInjured Patients (e.g., the 2016 version) were stronglyinfluenced by mechanism-driven criteria, with signifi-cant prevalence of overtriage [,,]. Overtriage ratesin international literature vary widely—from 12% to over70%—while undertriage remains particularly pronouncedin elderly adults [,–]. Accordingly, the 2022 DGU guideline update intro-duced refinements to the moderate-risk category (MRSI)and added geriatric-specific modifiers: systolic bloodpressure 91–100 mmHg, Glasgow Coma Scale score13–14, and AIS ≥ 3 injuries in two or more body regions[]. These were meant to improve sensitivity in elderlypatients, whereas HRSI remained focused on classicalphysiological indicators of critical risk and prehospitalemergency interventions. Existing literature supportsthe utility of such geriatric-aware adjustments [,].Moreover, pre-injury anticoagulation—common in theelderly—increases mortality and intracranial hemorrhagerisk, supporting its consideration within TTA protocols[–]. Using aggregated TR-DGU registry data, we aimed todescribe and compare in-hospital mortality across TTAcategories defined by the 2016 and 2022 DGU guide-lines, with specific focus on geriatric-specific MRSI ele-ments—systolic blood pressure 91–100 mmHg, GCS13–14, AIS ≥ 3 in ≥ 2 regions—and pre-injury anticoagu-lation status. We present age-stratified mortality find-ings to provide a robust epidemiological validation of theupdated criteria in elderly trauma patients. Materials and methods Study design This retrospective cohort study utilized data from theTR-DGU of the DGU, including the years 2018–2023.The TR-DGU was founded in 1993. The aim of this multi-centre database is a pseudonymized and standardizeddocumentation of severely injured patients. Data are rou-tinely documented during clinical care in four consecu-tive time phases from the site of the injury until dischargefrom hospital: (A) Pre-hospital phase, (B) Emergencyroom and initial surgery, (C) Intensive care unit and(D) Discharge. A separate ward or floor phase is notdocumented as an independent TR-DGU phase; over-all in-hospital outcomes are captured at discharge. Thedocumentation includes detailed information on demo-graphics, injury pattern, comorbidities, pre- and in-hos-pital management, course on intensive care unit (ICU),relevant laboratory findings including data on transfu-sion and outcome of each individual. The inclusion cri-terion is admission to hospital via emergency room withsubsequent ICU care or arrival at the hospital with vitalsigns followed by death before ICU admission. The infra-structure for documentation, data management, anddata analysis is provided by AUC – Academy for TraumaSurgery (AUC - Akademie der Unfallchirurgie GmbH), acompany affiliated to the German Trauma Society [].The scientific leadership is provided by the Committeeon Emergency Medicine, Intensive Care and TraumaManagement (Sektion NIS) of the German TraumaSociety. The participating hospitals submit their datapseudonymized into a central database via a web-basedapplication. Scientific data analysis is approved accordingto a peer review procedure laid down in the publicationguideline of TR-DGU. The participating hospitals are pri-marily located in Germany (90%), but a rising number Keywords Trauma team activation, Geriatric trauma, Geriatric patient, Geriatric modifier emergency medicine,Guideline, Undertriage ### Page 3 of hospitals of other countries contribute data as well(at the moment from Austria, Belgium, China, Finland,Luxembourg, Slovenia, Switzerland, The Netherlands,and the United Arab Emirates). Currently, more than30,000 cases from around 700 hospitals are entered intothe database per year. Participation in TR-DGU is volun-tary. For hospitals associated with TR-DGU, however, theentry of at least a basic data set is obligatory for reasonsof quality assurance. This analysis is an extension of the previously regis-tered project 2022-029 and is registered within the TR-DGU under the ID TR-DGU-2025-003. This study adhered to the “Strengthening the Report-ing of Observational Studies in Epidemiology (STROBE)statement”, and was performed in accordance with theethical standards laid down in the Declaration of Helsinkiand its modifications. Pseudonymized data were retrieved from the registryand analyzed retrospectively. Data quality was ensuredby predefined plausibility checks and standardized vari-able definitions within TR-DGU. All analyses adhered toTR-DGU publication by-laws; case counts and denomi-nators are reported for transparency. This study repre-sents a retrospective mapping analysis, in which registrycases were reclassified according to both the 2016 and2022 guideline criteria based on available registry data.Therefore, the study evaluates the theoretical perfor-mance and discriminatory capacity of the updated crite-ria rather than their prospective clinical implementation. Inclusion criteria The study period was 2018–2023. We included primaryadmissions to TR-DGU-participating hospitals in Ger-many with TTA, initial management in the trauma room,and subsequent admission to an intensive care unit(ICU). Eligible patients were trauma patients aged ≥ 60years. The age threshold of ≥ 60 years was selected toallow inclusion of patients in whom early age-relatedphysiological changes may already influence trauma out-comes. Patients had to meet the TR-DGU registry inclu-sion criteria, defined as a maximum Abbreviated InjuryScale (MAIS) score ≥ 3 or a MAIS score of 2 with ICUadmission. Injury severity was coded using the AIS, ver-sion 2005 update 2008, as applied in the TR-DGU duringthe study period. Exclusion criteria We excluded inter-hospital transfers (secondary admis-sions), patients dead on arrival without trauma roommanagement, and cases with missing key variablesrequired for analyses (e.g., systolic blood pressure orGlasgow Coma Scale). When variables required for sub-group analyses were missing, cases were excluded fromthe relevant subgroup only (complete-case approach). Data collection Exposure definitions and group assignment TTA criteria were defined according to the Germanguideline frameworks and mapped within TR-DGU fieldsas follows []: HRSI, high risk of severe injury: activation based onphysiological compromise. Within TR-DGU, most HRSIcriteria are explicitly documented and were identifieddirectly (Table). MRSI, moderate risk of severe injury: activation basedon mechanism and, in the 2022 update, geriatric-specificmodifiers. Mechanism-based triggers (e.g., high fall) werecaptured where documented. For motor vehicle colli-sions (MVC), MRSI was considered present when themechanism was coded as MVC and no higher priorityHRSI criterion was present. For the 2022 mapping, geri-atric modifiers were additionally flagged: systolic bloodpressure (SBP) 91–100 mmHg, Glasgow Coma Scale(GCS) 13–14, and multiple serious injuries (AIS ≥ 3) intwo or more body regions (Table). AIS-based injurypatterns were used retrospectively as surrogates for | Table 1 High Risk of severe injury (HRSI) Criteria for Trauma TeamActivation (TTA) according to the 2022 published guidelines bythe German Trauma Society (DGU) [] | | - | | A/B - Airway/Breathing Problem | | • Respiratory disturbance (SpO% < 90%) / need for airway management | | • Respiratory rate < 10 or > 29 | | C - Circulation Problem | | • Systolic blood pressure < 90 mmHg | | • Heart rate > 120/min | | • Shock index > 0.9 | | • Positive eFAST | | D - Disability Problem | | • GCS ≤ 12 | | E - Exposure Problem | | • Hypothermia < 35.0 °C | | Severe Injuries / Interventions | | • Unstable thorax | | • Mechanically unstable pelvic injury | | • Penetrating injuries to trunk/neck | | • Amputation proximal to hands/feet | | • Sensorimotor deficit after spinal injury | | • Prehospital intervention (airway management, chest decompression,catecholamine administration) | | - | | Table 2 Moderate risk of severe injury (MRSI) Criteria forTrauma Team Activation (TTA) according to the 2022 publishedguidelines by the German Trauma Society (DGU), Geriatricspecific modifiers (age 70 or older) [] | | - | | TTA should additionally be initiated in elderly patients afterrelevant trauma if: | | • Systolic blood pressure < 100 mmHg | | • Known or suspected traumatic brain injury and GCS ≤ 14 | | • Two or more injured body regions | | - | ### Page 4 anatomical injury burden and were not intended to rep-resent criteria available for real-time prehospital triagedecision-making. None: cases in which no HRSI or MRSI criterion couldbe identified in the registry fields; these activations wereassumed to reflect provider decision. Subgroups Age strata used for primary analyses were defined in5-year intervals (60–64, 65–69, 70–74, 75–79, and ≥ 80years), with a pooled 60–80 years category. Pre-injuryanticoagulation included vitamin K antagonists anddirect oral anticoagulants. Anatomical injury burden wascategorized as AIS ≥ 3 injuries in < 2 vs. ≥ 2 distinct bodyregions. Consistent with the national guideline definingSBP < 90 mmHg as an HRSI trigger, values recorded as90 mmHg were treated as ≤ 90 mmHg (critical) becauseapproximately 27% of cases in the critical range arerecorded at exactly 90 mmHg. GCS was categorized as15 versus 13–14 for analyses of geriatric MRSI items;GCS < 13 corresponds to an HRSI criterion. Outcomes The primary outcome was in-hospital mortality. Second-ary outcomes (where available) included intensive careunit length of stay and total hospital length of stay. Forthe present analyses based on aggregated tables, resultsare reported for mortality only. Statistical analysis Categorical variables were summarized as counts andpercentages; continuous variables as medians with quar-tiles. Group comparisons for categorical outcomes usedthe Chi-squared test. Age-stratified mortality propor-tions were compared across TTA strata (HRSI, MRSI,None) and by guideline mapping (2016 vs. 2022). Pre-defined subgroup analyses evaluated mortality by anti-coagulation status, by AIS ≥ 3 injuries in ≥ 2 regions, bySBP 91–100 vs. > 100 mmHg, and by GCS 13–14 vs. 15,each stratified by presence/absence of HRSI. Two-sidedp-values < 0.05 were considered statistically significant.Analyses were conducted using SPSS (version 29.0, IBM,Armonk, NY, USA). Ethics The study used pseudonymized registry data and wasconducted in accordance with TR-DGU governance. Thescientific dataset was further blinded for hospital nameand date/time of admission. Approval for scientific eval-uation of TR-DGU data is granted by the DGU SektionNIS. Data were initially collected for external quality con-trol, with written informed consent by the patients. Results Study population A total of 66,273 trauma patients from 674 hospitals par-ticipating in the TR-DGU were included in the analyses.Patients were stratified according to TTA criteria basedon the 2016 and 2022 guidelines of the German TraumaSociety (DGU): HRSI, MRSI, and None (provider deci-sion). Mortality rates were analyzed by age groups (60–64, 65–69, 70–74, 75–79, and ≥ 80 years) and by presenceor absence of specific MRSI modifiers (Table). Anticoagulation and mortality In elderly trauma patients (≥ 60 years), overall in-hospitalmortality was 29.3% in those with pre-injury anticoagula-tion compared to 20.3% in patients without. Within TTAsubgroups: HRSI mortality was 43.0% with anticoagula-tion versus 33.6% without; MRSI mortality was 17.5%versus 8.1%; and None mortality was 9.6% versus 4.1%.In the subset of elderly patients in the “None” categorywithout other criteria, mortality was 9.6% with anticoag-ulation compared with 4.1% without. Serious injuries in multiple body regions and mortality The effect of anatomical injury was assessed using AIS ≥ 3in ≥ 2 regions. Without HRSI: mortality was 12.5% withAIS ≥ 3 in ≥ 2 regions compared with 6.7% with < 2regions. At ≥ 80 years, mortality was 20.1% versus 11.2%.With HRSI present: mortality was 32.6% with AIS ≥ 3 in≥ 2 regions compared with 19.3% with < 2 regions. At ≥ 80years, mortality was 44.4% versus 27.9%. Validation of updated 2022 criteria vs. 2016 In the 2022 version of the German S3 Guideline on theTreatment of Polytrauma and Severely Injured Patients,age-stratified mortality showed a consistent gradientacross TTA groups (Fig.B; Table). At 60–64 years:HRSI 12.7%, MRSI 1.2%, None 0.9%. At 65–69 years:HRSI 19.0%, MRSI 1.9%, None 1.1%. At 70–74 years:HRSI 23.9%, MRSI 3.8%, None 1.9%. At 75–79 years:HRSI 31.2%, MRSI 8.3%, None 3.8%. At ≥ 80 years: HRSI47.5%, MRSI 16.6%, None 8.8%. In the 2016 guideline version, mortality patterns dif-fered (Fig.A; Table). At age 60–64 years: HRSI 13.9%,MRSI 0.9%, None 3.0%. At 65–69 years: HRSI 20.7%,MRSI 1.5%, None 4.4%. At 70–74 years: HRSI 26.5%,MRSI 2.9%, None 8.0%. At 75–79 years: HRSI 34.3%,MRSI 4.1%, None 11.5%. At ≥ 80 years: HRSI 50.6%,MRSI 11.8%, None 19.2%. Blood pressure (SBP 91–100 mmHg) and mortality In patients without HRSI: mortality was 11.9% versus5.8% at 75–79 years and 23.1% versus 12.1% at ≥ 80 years.In the pooled elderly cohort (60–80 years): 13.1% versus7.3%. In patients with HRSI: mortality was 26.2% versus ### Page 5 16.3% at 75–79 years and 43.2% versus 28.7% at ≥ 80years. Pooled 60–80 years: 30.2% versus 19.9%. Glasgow coma scale (GCS 13–14) and mortality In patients without HRSI: mortality was 10.7% versus4.2% at age 75–79 years and 18.8% versus 9.7% at ≥ 80years. In the pooled elderly cohort (60–80 years): 12.5%versus 5.6%. In patients with HRSI: mortality was 13.5%versus 6.5% at 75–79 years and 24.2% versus 14.3% at ≥ 80years. Pooled 60–80 years: 16.4% versus 8.6%. Discussion The present analysis demonstrates that the update ofthe German trauma guidelines in 2022 substantiallyimproves alignment of TTA criteria with outcome risk.In contrast to the 2016 version, where patients meetingmoderate-risk criteria (MRSI) paradoxically exhibitedlower mortality than those activated only by providerdecision, the updated framework establishes a clear hier-archy in which mortality is highest in patients with high-risk criteria (HRSI), intermediate in those with MRSI,and lowest in the “None” group [,], as shown inFig.. This change provides a transparent and reproduc-ible allocation of patients to activation criteria, which isessential for both clinical practice and benchmarking oftrauma system performance [,]. The introduction of geriatric-specific criteria into theMRSI category addresses a longstanding gap in traumacare [,]. With the demographic shift towards anaging population, elderly trauma patients represent anincreasing proportion of the severely injured cohort. InGermany and other European countries, the proportionof patients aged ≥ 70 years in trauma registries has risensteadily over the past decade []. This development hasmajor implications, as elderly patients show higher mor-tality, longer hospital stays, and more frequent complica-tions compared to younger adults with comparable injuryseverity [,]. At the same time, elderly trauma patientsare particularly prone to undertriage due to bluntedphysiological responses such as a preserved heart rateor systolic blood pressure that may still appear within“physiological limits” [,]. The explicit addition of systolic blood pressure 91–100mmHg as a trigger for MRSI reflects this phenomenon.The GCS of 13–14 in elderly patients recognizes thatmild alterations in consciousness in the geriatric groupcould be due to an intracranial injury, which may be oth-erwise underestimated when only a threshold of GCS < | Table 3 Age-stratified in-hospital mortality by trauma team activation group (%), according to the 2016 and 2022 German TraumaSociety (DGU) guideline criteria. High risk of severe injury (HRSI), moderate risk of severe injury (MRSI), and cases without identifiableHRSI or MRSI criteria (None) | | - | | Age group (years) | 2016 HRSI (%) | 2016 MRSI (%) | 2016 None (%) | 2022 HRSI (%) | 2022 MRSI (%) | 2022 None (%) | | 60–64 | 13.9 | 0.9 | 3.0 | 12.7 | 1.2 | 0.9 | | 65–69 | 20.7 | 1.5 | 4.4 | 19.0 | 1.9 | 1.1 | | 70–74 | 26.5 | 2.9 | 8.0 | 23.9 | 3.8 | 1.9 | | 75–79 | 34.3 | 4.1 | 11.5 | 31.2 | 8.3 | 3.8 | | ≥80 | 50.6 | 11.8 | 19.2 | 47.5 | 16.6 | 8.8 | | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | ### Page 6 13 is applied []. Finally, the addition of AIS ≥ 3 inju-ries in two or more body regions acknowledges that thecumulative burden of moderate injuries across multipleregions confers significant mortality risk in the elderly,even when no single injury meets classical “anatomic”high-risk criteria [,]. Each of these modificationsrepresents a reproducible trigger for TTA. While the addition of geriatric-specific criteriaimproves the sensitivity of TTA, it may also carry therisk of increased overtriage []. Expanding the spectrumof moderate-risk criteria inevitably raises the number ofpatients triggering activation, some of whom may ulti-mately not require the full resources of a trauma team.Given the finite availability of surgical, anesthesiologic,and radiological capacity in most centers, unnecessaryactivation has the potential to divert personnel fromother critical tasks, strain system efficiency, and increasecosts [,,]. Therefore, while the 2022 criteria rep-resent an important step toward reducing undertriagein elderly trauma patients, their impact on overtriage isessential to optimize trauma system performance. Theultimate goal is to minimize preventable deaths whilesafeguarding finite medical resources. International con-sensus statements state that acceptable overtriage ratesmay range between 25 and 35%, whereas undertriageshould remain below 5% []. Accordingly, further evaluation of the 2022 guide-line update should not only confirm its ability to reduceundertriage, but also quantify its impact on overtri-age and system resource allocation. Prospective registrystudies are needed to determine whether the revised cri-teria achieve a good balance of sensitivity and specificityin real-world practice. Nevertheless, the validation of these criteria in thepresent registry analysis confirms their clinical util-ity. Mortality increased consistently when the geriat-ric-specific thresholds were met, whether defined bylow-normal systolic blood pressure, GCS 13–14, or mul-tiple-region injury. Importantly, these patterns held trueeven in the absence of high-risk physiological derange-ments, demonstrating that these newly defined MRSIelements capture a subset of elderly patients at relevantrisk who would otherwise fall into the “None” group. Theresult is a more precise and transparent stratification oftrauma patients. Another important observation in our study is theeffect of pre-injury anticoagulation, which was associ-ated with significantly higher mortality across all TTAstrata. This finding is consistent with prior registry stud-ies showing that anticoagulated trauma patients haveincreased rates of intracranial hemorrhage, transfusion,and mortality [,,]. Given the widespread andincreasing use of vitamin K antagonists and direct oralanticoagulants in the elderly population, the integrationof anticoagulation status into triage and activation algo-rithms should be strongly considered in future guidelinerevisions []. Overall, these findings underscore the importance ofa precise and reproducible TTA process. Accurate TTAensures timely availability of surgical, radiological, andintensive care resources, which is critical for preventingavoidable mortality and morbidity []. By addressingdemographic realities and formally integrating geriatric-specific risks into the triage algorithm, the 2022 guidelineupdate represents a significant step toward more effec-tive trauma care for elderly patients. Limitations Several limitations must be acknowledged. First, the anal-ysis is based on retrospective registry data and is there-fore subject to documentation bias, coding inaccuracies,and unmeasured confounding. In addition, this studyrepresents a retrospective mapping analysis and doesnot evaluate the prospective clinical implementationof the 2022 criteria. Second, the “None” group is inher-ently heterogeneous and may include both undertriagedhigh-risk patients and lower-risk cases activated due toclinical uncertainty. Third, AIS-based variables were usedretrospectively as surrogates for anatomical injury bur-den and are not applicable for real-time prehospital tri-age decision-making. Fourth, the use of a complete-caseapproach may have introduced selection bias, particu-larly if missing data were not randomly distributed acrosspatient subgroups. Fifth, the inclusion criteria of the TR-DGU focus on patients requiring ICU admission or thosewho died early, which may lead to an overrepresentationof more severely injured patients and limit generaliz-ability to less severely injured populations. Finally, theprimary outcome was in-hospital mortality; functionaloutcomes, quality of life, and long-term disability werenot assessed. Alternative age cutoffs and trauma systemsoutside Germany may yield different results. Since April 2025, TTA criteria have been explicitly andsystematically documented within the TR-DGU, whichwill enable more accurate evaluation of guideline imple-mentation and facilitate future analyses of field triage. Conclusion This study validates the updated 2022 DGU TTA crite-ria using national registry data. In contrast to the 2016version, the new framework provides a transparent allo-cation of patients, with mortality consistently highest inHRSI, intermediate in MRSI, and lowest in patients with-out criteria. The addition of geriatric-specific criteria—systolic blood pressure 91–100 mmHg, GCS 13–14, andAIS ≥ 3 injuries in multiple regions—proved effective inidentifying elderly trauma patients at increased risk. ### Page 7 Abbreviations AIS Abbreviated Injury Scale DGU German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie) GCS Glasgow Coma Scale HRSI High Risk of Severe Injury ICU Intensive Care Unit MAIS Maximum Abbreviated Injury Scale MRSI Moderate Risk of Severe Injury SBP Systolic Blood Pressure TR-DGU TraumaRegister DGU® TTA Trauma Team Activation Author contributions PF, PH, RL, US, MM, TJ, DK, and the Committee on Emergency Medicine,Intensive Care and Trauma Management (Sektion NIS) of the GermanTraumaSociety (DGU) contributed to the conception and design of thestudy as well as todata acquisition. PH, PF and RL conducted the dataanalysis andinterpretation. PF and PH contributed equally to the preparationanddrafting of the manuscript. DK supervised the study and critically revisedthemanuscript. All authors contributed to the revision. All authors have readandapproved the final published version of the manuscript. Funding Not applicable. Data availability The datasets generated and analysed during the current study are not publiclyavailable due to ethical and legal restrictions but are available from thecorresponding author upon reasonable request. Declarations Ethical approval This study was a retrospective analysis of anonymized registry data from theTR-DGU of the German Trauma Society. The study protocol was approved bythe scientific review board of the TR-DGU and registered under the projectID TR-DGU- 2025-003. All data analyzed were pseudonymized prior to accessand analysis. No individual patient identifiers were used. Therefore, informedconsent was not required. The research was conducted in accordance withthe principles of the Declaration of Helsinki. Consent for publication Not applicable, no identifiable patient data is included. Competing interests The authors declare no competing interests. Author details 1Department of Trauma and Orthopaedic Surgery, BG UnfallklinikFrankfurt, Frankfurt am Main, Germany 2Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany Received: 22 January 2026 / Accepted: 27 May 2026 References 1. Organisation WH. Fact Sheet [Internet]. 2024 [zitiert 9. September 2025].Injuries and violence. Verfügbar unter:. 2. Li C, Jiao J, Hua G, Yundendorj G, Liu S, Yu H. u. a. Global burden of allcause-specific injuries among children and adolescents from 1990 to 2019: aprospective cohort study. Int J Surg Lond Engl 1 April. 2024;110(4):2092–103.. PubMed PMID: 38348839. 3. Naghavi M, Ong KL, Aali A, Ababneh HS, Abate YH, Abbafati C. u. a. 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