in a retrospective observational study recently published in british medical journal , lockey et al .   note that trauma patients intubated without sedation before reaching hospital had a poor prognosis . they looked at the records of 1623 patients registered in a helicopter emergency medical service database over six years ; of these , 486 had data on survival . out of 486 patients , only one survived ( 0.2% ) . from this , the authors associate non - drug - assisted airway management with poor prognosis in trauma patients . the study design in the paper by lockey et al . was lacking ; observational and retrospective , it provided no information on the trauma patients intubated with sedation , no incidence rate of cardiac arrest in the study group , and no objective measure of the severity of injury of the study patients . it is also not clear from the authors ' comments whether they are calling into question the procedure itself or the capacities of those performing it . nevertheless , it did highlight the quandaries surrounding airway management in trauma patients before reaching hospital , and raised two fundamental questions . first , is endotracheal intubation necessary , efficient and effective in the prehospital treatment of the trauma patient ? second , is sedation or neuromuscular blockade useful for the intubation of the trauma patient ? airway management is widely considered the highest priority in the management of the critically injured patient . the rationale for invasive airway management includes facilitating oxygenation and ventilation , and protecting the patient from aspirating the contents of the stomach , or blood from the upper airway . consequently , one might expect intubation and mechanical ventilation to be associated with decreased neurological damage as a result of preventing asphyxia and hypoxia . however , some experts consider intubation before reaching the hospital as deleterious , dangerous , and a waste of precious time in trauma patients without a compromised airway . although there are no broad , prospective , controlled trials comparing the basic and advanced prehospital management of adult trauma patients , several studies have highlighted the benefits of endotracheal intubation before the hospital has been reached . for example , winchell and hoyt   showed that intubation in the prehospital setting improved survival in patients characterized by a glagow coma scale score of 8 or less with blunt injury from 64% to 74% . found that there were between 8 and 19 extra survivors per 100 blunt - trauma patients treated in the advanced prehospital management group ( 51% of intubated patients ) compared with more basic prehospital management ( 10% of intubated patients ; p < 0.001 ) . others , however , have not found any advantage of intubation on the scene in terms of outcome . for instance , eckstein et al .   reported that patients who had bag - mask ventilation had 5.3-fold higher adjusted survival rates than patients who had on - scene tracheal intubation . in a randomized study , gausche et al .   compared the survival and neurological outcomes of paediatric patients treated with bag - valve - mask ventilation with patients treated by tracheal intubation in a prehospital setting . they found no significant difference between the two groups in survival or in the rate of achieving a good neurological outcome . possibly the greatest factors in the incidence of failure in intubating trauma patients are inadequate sedation , patient combativeness , lack of practice and the concomitant need for in - line cervical spine stabilization . all this can be compounded by airway reactivity ( gag and cough reflexes ) , which can be present even in trauma patients with a glasgow coma scale score of 3 . these reflexes contribute to the increase in difficulty of intubation and the rate of complications ( vomiting or aspiration ) . the ability to intubate trauma patients with success without pharmacological aids is a reflection of the initial severity of patient . thus , the poor prognosis of patients described in the paper by lockey et al . probably has little to do with the intubation technique , but instead reflects the patients ' pre - existing high probability of a fatal outcome and is therefore not surprising . rapid sequence intubation ( rsi ) with succinylcholine has been associated with a decrease in intubation failures and complications in several studies , and has become the ' gold standard ' for emergency intubation attempts . in rsi , the patient is given a potent induction agent ( such as thiopental or etomidate ) followed immediately by administration of a rapidly acting neuromuscular blocking agent ( such as succinylcholine ) to induce unconsciousness and motor paralysis ; the patient is then intubated . all this is preceded by a preoxygenation phase to permit a period of apnea to occur safely until intubation has been achieved . as well as fewer failures with rsi , emergency systems using emergency physicians in the prehospital setting seem have better success with intubation attempts . however , it remains unclear whether such improved outcomes are due to additional training or are simply due to additional experience . several studies suggest that timely intubation in the severely injured patient at the scene improves outcome . conversely , inadequate airway management in this patient population is the primary cause of preventable mortality . endotracheal intubation should therefore be considered necessary , efficient and effective in the treatment of the trauma patient before reaching hospital . the use of rsi with neuromuscular blockade remains the procedure of choice , even in the unconscious trauma patient ; sedation or neuromuscular blockade therefore seems to be useful for the intubation of trauma patients . whether the presence of an emergency physician at the scene ( as opposed to a paramedic experienced in rsi ) is associated with better outcome merits additional study .