A 19-year-old male motorcyclist, who was not wearing a helmet, lost control of his bike at approximately 70 mph (160 km/h), crashing into railings. Witnesses reported that the impact of the crash was taken by his head and face against the railings. His pillion passenger sustained multiple injuries. On arrival at the Accident and Emergency department (A&E), he was transferred to the A&E trolley with in-line manual cervical spine immobilization. A stiff-neck collar, sand-bags and tape were applied. He was making some respiratory effort, with visible chest wall movements, but his airway was severely compromised secondary to facial trauma and haemorrhage. Chest examination was normal and remained so throughout the resuscitation. Examination of the circulation revealed uncontrollable haemorrhage from the head and face. There was no evidence of any other source of blood loss. The capillary return was greater than 8 s, his pulse rate was 120, and systolic blood pressure was 50mmHg. His Glasgow Coma Score was 3. His pupils were fixed and dilated. His airway was immediately secured with a cuffed oral endotracheal tube. He was ventilated at a rate of 20 inflations per min. Direct manual pressure was applied to obvious sources of haemorrhage. Intravenous access was established via three large-bore cannulae. Warmed fluids were infused under pressure. In total, I unit of crystalloid, 10 units of colloid, 2 units of O-negative blood and 4 units of type-specific blood were infused. The sytolic blood pressure was never greater than 50mmHg. Radiographs of the lateral cervical spine, chest and pelvis were taken. Despite constant pressure applied to the head and face wounds, severe haemorrhage continued. Repeated examinations revealed no other sources of haemorrhage. The patient was assessed by senior maxillofacial surgeons who were unable to add any further immediate treatment. Following a total resuscitation time of I h 20 min, the blood pressure remained below 50 mmHg, with continued uncontrollable haemorrhage. His pupils remained fixed and dilated and there was no spontaneous respiratory effort. Resuscitation was therefore stopped after discussion with the A&E consultant. Post-mortem examination included the following findings: Le Fort 2 and 3 fractures, multiple mandibular fractures, multiple full-thickness facial lacerations up to 14cm long, frontal, temporal, sphenoid and cribiform plate fractures, blood over the surface of the brain, and severe dislocation of the atlantooccipital joint with marked mobility, demonstrated on manipulation.