Effective management of the airway may have the greatest impact on mortality and morbidity of all pre-hospital interventions. The administration of a pre-hospital anaesthetic may not only facilitate effective management and protection of the airway but may also be fundamental to maintaining adequate ventilation and reducing times to definitive treatment for casualties who are trapped and those with major chest and head injuries. Pre-hospital anaesthesia is a highly skilled technique that requires considerable training and experience. Inappropriate attempts to anaesthetise critically injured casualties may prove fatal if the operator does not have the requisite knowledge, skills and equipment. For those that do, this article provides an operational framework within which pre-hospital anaesthesia can be developed (Box 5).