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A 24- year- old man fell approximately 30 feet while working as a roofer; he had a loss of consciousness following the impact but regained consciousness and was agitated and able to protect his airway during transport via EMS to a level one trauma center. On arrival, his exam had deteriorated, and he arrived with a Glasgow Coma Scale (GCS) score of 6T. He was intubated on arrival in the emergency department trauma bay. His initial exam demonstrated multiple facial and scalp lacerations and abrasions, along with ecchymosis and edema surrounding the right orbit requiring lateral canthotomy. His pupils were 4 mm and sluggish bilaterally, he had cough and gag reflexes and a left corneal reflex; he withdrew all extremities to pain.