A bus was involved in a roll-over road traffic accident. Most occupants were ejected from the vehicle. Primary triage revealed 9 dead, 1 P4 (unsalvageable), 5 P1 (immediate life threat) and 30 less severely injured patients. Two prehospital doctors performed a secondary triage, provided medical supervision and performed critical care interventions where necessary.

A young man initially triaged as P4 was upgraded to P1. Primary examination revealed an unmaintained airway with vomit in the pharynx, central trachea, distended neck veins, chest wall abrasions, deep respiratory gasps (6 breaths/min), absent breath sounds and a weak central pulse. The Glasgow Coma Scale (GCS) was 6/15 (E1, V1, M4) and pupils were equal, 3 mm and reactive to light. The left femur was fractured.

Monitoring confirmed a sinus tachycardia of 150 beats/min, but oxygen saturation (Spo₂) and non-invasive blood pressure (NIBP) were unrecordable. Spo₂ of 60% was obtained with bag–valve–mask ventilation.

A rapid-sequence induction using etomidate (16 mg intravenous) and suxamethonium …