A 19-year-old man was buried when the walls of the trench he was digging collapsed. Bystanders exposed the head and chest, and called the emergency services. The paramedic applied a cervical collar. Primary survey revealed a patent airway, spontaneous respirations and saturations of 99% on oxygen. Good pulses were palpated bilaterally at 90 beats/min and intravenous (iv) access was secured. The Glasgow Coma Scale (GCS) was 3/15.

The patient began groaning in response to pain, and the GCS was revised to 4/15. Pupils were 3 mm in diameter, equal and reactive to light. The prehospital doctor administered ketamine 100 mg iv to aid extrication and the patient was secured onto a spinal board.

Once in the ambulance, the patient displayed decorticate posturing in response to pain (GCS 6/15). Secondary survey excluded obvious head injury. Surgical emphysema and bruising were noted on the right side of the chest, without flail segment. The trachea was central with good breath sounds …