INTRODUCTION: Hollow viscus injuries (HVIs) are difficult to diagnose, and delay to diagnosis negatively impacts outcome. We sought to determine the incidence of HVI, mortality, and the time to primary HVI procedure in older adult ( ≥ 65 y) trauma patients compared to adult patients (15-64 y). METHODS: This retrospective cohort study included patients age ≥ 15 in a motor vehicle collision included in years 2021-2023 of the Trauma Quality Improvement Program database. Adjusted odds of HVI were classified based on relevant International Classification of Diseases-10th Revision diagnosis codes. A multivariable logistic regression model controlling for injury severity and other relevant covariates was calibrated to determine odds of mortality between cohorts. The effect of time to primary HVI procedure on mortality was compared using a multivariable cox proportional hazards model adjusted for the same covariates to identify risk of death over time. RESULTS: A total of 783,952 patients were involved in a motor vehicle collision during the study period resulting in 12,156 HVI (10,781 adult and 1375 older adult). Adjusted odds of HVI were 48% lower in older adult patients. In the 2953 patients undergoing an HVI operation, the likelihood of mortality was eight times higher in older adult patients compared to adults, with older adult patients taking nearly double the time to the operating room. Additionally, delays from admission to HVI operation of greater than 1 h were associated with higher probabilities of death for older adult patients, and by 48 h their probability of death was 13 percentage points higher (16.20% for older adults versus 3.28% for adults). CONCLUSIONS: Older adult patients decompensate more rapidly than their younger counterparts, making prompt diagnosis and surgical intervention essential to obtaining the best outcomes. Future research should focus on how to optimize timely HVI diagnosis and intervention in older adult patients to minimize the disparity in outcomes between age groups.