Scenario — Deep burn with suspected inhalation injury at community bonfire event

advanced Trauma · Adult · 35yr · male

Patient Information

Dispatch	You are called to a 35YO 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 — 35yr (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

Scenario Progression and Treatment Objectives

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 Priority 1 ambulance 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.
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 — Priority 1 pre-notification to receiving facility 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

How did you go?

← Prev ← → navigate · Space reveal

🖨 Export PDF Next →

Signs/Symptoms	Persistent cough, hoarse voice, burning pain to forearms and anterior chest. States he cannot feel pain at the pale dry areas on his left forearm. Anxious and distressed.
Allergies	NKDA — no known drug allergies.
Medications	Nil regular medications.
Pertinent History	Nil significant past medical history. Non-smoker. Fit and well. No previous burns.
Last Oral Intake	Had a beer approximately 30 minutes ago. Last solid food approximately 2 hours ago.
Events Leading	Patient was standing watching the community bonfire when someone added what he believes was a petrol-soaked material to the fire, causing a sudden flare. He was approximately 1 metre from the fire at the time and was caught in the flash. He was in an open outdoor environment but was in close proximity to the flame source.
Treatment Prior	Bystanders poured a water bottle over his arms — approximately 1 minute of cooling prior to EHS arrival. No other treatment.

Onset	Sudden — bonfire flared approximately 15 minutes ago. Exposed to flash flame and superheated gases for estimated 3–5 seconds in enclosed proximity before bystanders pulled him back.
Pain	Severe burning pain to both forearms (partial-thickness areas) and upper chest. Left mid-forearm — no pain in pale/dry area (full-thickness). Pain score 8/10 overall.
Quality	Burning, intense, constant to partial-thickness areas. No sensation at full-thickness left forearm area.
Radiates	Nil radiation.
Severity	8/10