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Well he's certainly having a bad day. I'd still like to know what your total door to door time will be. What resources does the hospital have immedietly available? ie is anesthesia and ENT in house and available? Start by moving the BP cuff and pulse ox to the left arm and recheck the values. If the sat is still only 95% it's very likely that you are either missing a pneumo/hemo or blood flow to the lungs has been compromised. I would still be very concerned for additional injuries, or damage to major vessels that has been missed due to the other internal bleeding; unfortunately, there isn't a lot you can do right now. If the BP is still low with a low pulse I would say it's a combination of blood loss, and with the description of the hematomas have to wonder if they aren't directly impinging on the heart and/or the aorta and impeding flow, OR putting enough pressure on the carotid bodies to trick the body into thinking it's hypertensive and needs to compensate; either way the treatment will be the same. The condition of the right arm...with those injuries and the hematomas that's to be expected; nothing to be done until you get to a vascular surgeon. What about his right leg, and the whole right side of his body? TXA would good, blood would be very good; he does need volume and blood would be best. An epi drip would also be good. Now the hard part...keen or not, look the doctors square in the eye and remind them that this is a patient with a KNOWN compromised airway who is KNOWN to be a difficult (potentially very difficult) intubation. Ask them if they really, really want to take a person like that and put them into a small, cramped plane where the emergent crich that will be needed if nothing is done now will be very difficult to do. Or just tell them that he has to be intubated...like yesterday. If anesthesia and ENT are available I would confer with them and think about deferring to them; if the anesthesiologist can do an awake intubation, or a fiberoptic intubation that would be best. His crichoid membrane needs to be marked and ENT (if available) needs to be standing by with a scalpel if anything goes wrong. If they aren't available...make your plan and be ready for a bad failure. Have a backup ready (LMA and bougie), if you are good with video laryngoscopy go with that to start, if not then go with DL. Have someone available to assist with manipulating the larynx, again, have the crich marked and a designated person standing by with a scalpel. Go with sux and a very small dose of ketamine. If you can't intubate but the LMA works try passing either a bougie (or tube if it's and intubating LMA) through it; if you can't do that you still have to cut, but the pressure is off somewhat. So to recap: TXA, blood and pressors for support, a tube in the trachea by intubation or crich, keep him sedated with fentanyl (that'd help with any potential withdrawal too) ketamine, and rocuronium if it becomes neccasary. Take only this guy; your hands are going to be full.