Trauma Advanced

Deep burn with suspected inhalation injury at community bonfire event

Adult · 38yr · male

Patient Information

Dispatch: You are called to a 38YO male at the Australia Day community bonfire event at Langley Park. Bystanders report he was standing too close when the bonfire flared unexpectedly — his arms and chest are burned and he is coughing.
Patient: Marcus Holt — 38yr (80kg)
Incident History: Pt was attending the Australia Day bonfire event at Langley Park when a petrol-accelerated bonfire flared suddenly. He sustained burns to his anterior chest and both forearms. Bystanders pulled him back. He is conscious and walking but coughing persistently and his voice sounds hoarse.
Emergency Contact: Sarah Holt (Wife) — 0412 774 309

Initial Rapid Assessment

Response: Alert
Airway: Patent on arrival but hoarse voice noted. Singed nasal hairs and eyebrows visible. Soot visible around nostrils and mouth. No audible stridor at rest — HIGH RISK for progressive airway oedema.
Breathing: Persistent cough present. Laboured — accessory muscle use visible. RR elevated. SpO2 91% on room air. No audible wheeze at this time.
Circulation: Radial pulse rapid and strong. Skin on forearms — partial-thickness burns (red, blistered, wet appearance) and areas of full-thickness burn (pale/waxy, dry, no sensation reported by patient). Anterior chest — partial-thickness burns across upper chest approximately 9% TBSA.
Disability: GCS 15 (E4V5M6). Orientated to time, place and person. Anxious and distressed. Complaining of significant pain to forearms; describes no pain at full-thickness areas.
Exposure: Anterior chest upper segment burned — approximately 9% TBSA (Rule of 9s). Both forearms burned — approximately 9% TBSA combined (front of each forearm). Total estimated TBSA ≈ 18%. Mix of partial-thickness (blistered, red) and full-thickness (pale/waxy/dry, no sensation). Clothing partially melted to chest area — DO NOT REMOVE. Singed eyebrows and nasal hair confirmed.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	91% (RA)	Moderate	22	108	128/82	2s	15	4 4 ++	36.8	–	8
10 mins	97% (O2 NRB 15L/min)	Mild	18	100	124/80	2s	15	4 4 ++	36.7	–	6

History Taking

Treatment Response

Diagnosis

This patient is suffering from a mixed partial-thickness and full-thickness burn injury with suspected inhalation injury, estimated at approximately 18% TBSA involving the anterior chest and bilateral forearms, with high risk of progressive upper airway compromise secondary to thermal injury to the airway mucosa.

Facilitator Triggers — if trainees miss a critical step

! (If singed nasal hairs and hoarse voice are not identified within the first 2 minutes: Marcus begins to develop audible stridor. Prompt: 'The patient's voice is becoming increasingly hoarse and you can now hear a high-pitched noise as he breathes in.')
! (If high-flow oxygen via non-rebreather mask is not applied promptly: SpO2 drops to 88% on room air at 5 minutes. Prompt: 'The patient is becoming more agitated and his lips look dusky.')
! (If clothing adhered to wound is attempted to be removed from chest: Prompt: 'As you attempt to remove the fabric it is clearly adhered to the wound — do not continue removal, leave in place.')
! (If cooling is not applied or is applied for less than 20 minutes: Facilitator notes that tissue injury continues — prompt trainee to reconsider cooling duration. Prompt: 'How long has cooling been applied? The CPG requires a minimum of 20 minutes.')
! (If full-thickness areas are not identified separately from partial-thickness areas during TBSA assessment: Prompt: 'The patient tells you he can feel severe pain in his red blistered areas but cannot feel anything in the pale, dry, waxy patch on his left forearm — what does this suggest about burn depth?')
! (If Methoxyflurane (Penthrox) is considered for analgesia: Confirm it is NOT contraindicated here — patient is alert, orientated, GCS 15, no head injury, not intoxicated — Penthrox is appropriate. However, remind trainees to monitor for over-sedation and ensure the patient can self-administer.)
! (If trainee does not escalate urgency or call for ambulance given inhalation injury signs: Prompt: 'Hoarse voice and singed nasal hair in a burn patient — what does this tell you about the airway? What is your priority now?')

Treatment Objectives

1 Ensure scene safety — confirm bonfire is controlled and patient is away from heat source before approaching.
2 Don appropriate PPE (gloves, eye protection).
3 Perform Primary Survey with c-spine consideration (mechanism does not suggest spinal injury — no log roll required, c-spine clearance appropriate).
4 Immediately identify inhalation injury risk — singed nasal hairs, hoarse voice, soot around nostrils and mouth, persistent cough, exposure to superheated gases.
5 Apply oxygen via non-rebreather mask (NRB) at 10–15 L/min immediately — target SpO2 94–98%. NOTE: carbon monoxide inhalation may provide a falsely normal SpO2 reading — treat the clinical picture, not the number alone.
6 Call for urgent ambulance via CSP immediately — inhalation injury with hoarse voice represents a time-critical airway emergency requiring Advanced Care backup and transport to a Major Trauma Centre / Tertiary Burns Centre.
7 Begin burn cooling: apply cool running water (approximately 15°C) to all burned areas for a minimum of 20 minutes. Begin as soon as practicable — bystanders have already applied approximately 1 minute, so continue for at least 19 further minutes.
8 DO NOT remove clothing adhered to the wound — remove only non-adhered clothing and jewellery from affected limbs before oedema develops.
9 Assess and document TBSA using Rule of 9s: Anterior chest upper segment ≈ 9%; Both forearms ≈ 9% combined. Estimated total TBSA ≈ 18%.
10 Identify and document burn depth: Partial-thickness (red, blistered, moist, painful) — bilateral forearms and anterior chest. Full-thickness (pale, waxy, dry, no sensation) — area of left forearm. Record both for handover.
11 After 20 minutes cooling is complete, apply damp sterile dressings to all burned areas.
12 Perform Vital Sign Survey — document RR, SpO2, HR, BP, GCS, PERL, pain score, skin temperature, CRT.
13 Perform Secondary/CNS Survey — assess for any other injuries sustained in the incident.
14 Administer Methoxyflurane (Penthrox) 3 mL inhaled via Penthrox inhaler for analgesia — patient is alert (GCS 15), orientated, no head injury, no alcohol/drug impairment sufficient to preclude use. Patient must self-administer. Charcoal filter must be attached. Monitor for over-sedation. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
15 Reassess pain score pre- and post-Methoxyflurane administration.
16 Monitor patient persistently — record full observations every 5 minutes given time-critical inhalation injury status.
17 Monitor closely for signs of progressive airway compromise: increasing hoarseness, stridor, increasing respiratory distress, decreasing SpO2, decreasing GCS. If any deterioration — urgent IMISTAMBO handover to CSP immediately.
18 Keep patient warm — avoid hypothermia during cooling; cover non-burned areas with dry blanket after cooling is complete.
19 Do NOT apply hydrogel dressings in preference over water cooling — water cooling for minimum 20 minutes is preferred.
20 Prepare for handover: document time of burn injury (not time of arrival), TBSA estimate, burn depth, inhalation injury signs, cooling duration, oxygen delivery, Methoxyflurane administered, vital sign trends.
21 Scenario ends on arrival of ambulance and IMISTAMBO handover.
22 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Burn Trauma · Smoke & Carbon Monoxide Inhalation · Dyspnoea & Respiratory Distress · Oxygen Delivery · Penthrox Inhaler Administration · Primary Survey · Secondary & CNS Survey

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