January 5, 2026

A 48-year-old male fell from scaffolding at work, is currently seizing and otherwise unresponsive. He has suffered trauma to the head, but no other bruising or trauma, with snoring respirations and significant saliva from the mouth. He is also vomiting. 

You appropriately manage the airway with full C-Spine precautions.  

You evaluate the Glasgow Coma Scale (GCS): 

• Eyes: Not opening even with noxious stimuli=1 

• Verbal: Making only incomprehensible sounds=2 

• Motor: He withdraws from noxious stimuli=4 

• Total=7 

How will you manage his airway? It is clear that he needs an airway. He is seizing, and this must be controlled immediately. 

185/105, p=45, Pulse Ox=93%, Glucose 133 

You chose Versed 2.5 mg IV with control of seizures. He is now exhibiting decerebrate posturing. GCS is now 6. 

You are 30 minutes from the trauma center; air support is grounded due to weather, and the patient’s trajectory is getting worse. There is a gag reflex. 

You are trained in rapid sequence intubation (RSI) and so is your partner; you also have an EMT to assist. The three of you go through the 7 Ps: 

1. Prepare (all equipment, suction, tubes, recue airways, meds, tubes, tube holder, capnography, and video equipment) 

2. Preoxygenate 

3. Premedicate (Ketamine 1-2 mg/kg) 

4. Paralytic medications (Rocuronium 1-2 mg/kg) 

5. Positioning (C-Spine precautions with this patient) 

6. Place tube (and confirm with visual partner confirmation capnography waveform, breath sounds and Pulse Ox as well as colorimetric CO2) 

7. Post-intubation care (watch the waveform, pox, and patient condition until arrival) 

Excellent job by the crew. The patient is found to have an expanding SDH and is taken rapidly to surgery. Decompression is complete, and after a long recovery, the patient is left with memory issues but is physically at baseline. 

Summary 

• RSI is for trained medics, and they must be with another trained RSI medic as well as a third assistant.  

• Video equipment, as well as backup airway care, is required. 

• Complete the 7 Ps for intubation under RSI. 

• Constant patient monitoring is required. When you sedate and paralyze a patient, their total care is in your hands. 

We are all in this together. Always call medical control for support. 

Sincerely, 

Don Spaner, MD