Health services are challenged with providing trauma care to an increasingly elderly population. The objectives of this study were to determine the in-hospital mortality for injured elderly patients, and by analysing key features of their management, to ascertain whether these trauma patients were managed less aggressively than their younger counterparts. Main outcome measures included; use of resuscitation room facilities, senior medical staff involvement, admission to intensive care units, transfers to regional neurosurgical centres and mortality. Three thousand seven hundred patients initially managed in a resuscitation room were significantly younger (mean age 43) than those not treated in this area (mean age 54, 95% CI 10.7-12.4). Considering seriously injured patients with a significant head injury (who did not present in coma) those transferred to neurosurgical care were younger (mean age 44) than patients who were not transferred (mean age 49, 95% CI 1. 6-8.6). Logistic regression analysis showed that age did not have a significant independent effect on the seniority of medical response from key specialties. For the severely injured, the odds of being admitted to an intensive care unit when aged 70 in comparison to age 30 were 0.7436 (95% CI 0.5787-0.9559). Overall in-hospital mortality of the 290 elderly patients who had sustained major trauma was 42.1%. Significantly more of the elderly died than would be predicted. Age appears to be an independent factor in the process of trauma care in Scottish hospitals. We consider that outcomes for the injured elderly could be improved by a more dynamic approach to their management.