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Background Every year, 1.3 million lives are lost to road traffic injuries (RTIs). 90% of these deaths disproportionately occur in Lower-Middle Income Countries (LMICs). Due to frailty and reduced physiological resilience, elderly populations are at higher risk of RTIs and poor outcomes, versus younger populations. Further, according to the World Health Organization (WHO), the global elderly population will double by 2050, indicating that this group will be at an even higher risk of RTIS. Objectives Our study aims to utilize Emergency Medical Services (EMS) data to better understand the trends, types, injuries, patient characteristics, and outcomes of RTIs involving the elderly, ultimately contributing to more targeted and effective road safety policies and interventions. Methods We analyzed secondary EMS data during 2022 and 2023 from the Emergency Services Department (Rescue 1122) in the province of Punjab, Pakistan. RTI data in patients aged  ≥  65 years was extracted from the database for age, gender, education, response time, injury type, RTI victim type, location of injury, and victim outcome. Multivariable analysis was carried out using multiple logistic regression to obtain an adjusted odds ratio with a 95% confidence interval for on-scene mortality. Results From 4.2 million EMS activations, data on 34,345 RTIs in elderly patients was analyzed. Patients had a mean age of 70.12 years, and 77% (26,608) were males. The most common injury type was soft tissue injury (24,166; 70.36%), followed by limb injury (5,126; 14.9%), and head injury (2,590; 7.5%). Most victims suffered injuries as passengers (11,396; 37.2%). The mean response time was 7.19 minutes, and the on-scene mortality rate was 1.3% (443). The odds of on-scene mortality increased with increasing response time (AOR: 1.05, CI: 1.04–1.07), while an increase in the degree of urbanization was associated with decreasing odds of on-scene mortality (AOR: 0.99, CI: 0.98–0.99). Head injuries (OR: 24.49, CI: 20.11–29.93) and pedestrian injuries (Adjusted OR: 1.40, CI: 1.06–1.84) were strongly associated with on-scene mortality. Conclusion Our study revealed that head and pedestrian injuries emerged as key factors for on-scene mortality in elderly patients of Punjab, Pakistan. These findings necessitate targeted interventions to encourage a rapid pre-hospital response to lower on-scene mortality rates.