((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?'))

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.

• Ensure scene safety — confirm bonfire is controlled and patient is away from heat source before approaching.
• Don appropriate PPE (gloves, eye protection).
• Perform Primary Survey with c-spine consideration (mechanism does not suggest spinal injury — no log roll required, c-spine clearance appropriate).
• Immediately identify inhalation injury risk — singed nasal hairs, hoarse voice, soot around nostrils and mouth, persistent cough, exposure to superheated gases.
• 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.
• 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.
• 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.
• DO NOT remove clothing adhered to the wound — remove only non-adhered clothing and jewellery from affected limbs before oedema develops.
• Assess and document TBSA using Rule of 9s: Anterior chest upper segment ≈ 9%; Both forearms ≈ 9% combined. Estimated total TBSA ≈ 18%.
• 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.
• After 20 minutes cooling is complete, apply damp sterile dressings to all burned areas.
• Perform Vital Sign Survey — document RR, SpO2, HR, BP, GCS, PERL, pain score, skin temperature, CRT.
• Perform Secondary/CNS Survey — assess for any other injuries sustained in the incident.
• 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.
• Reassess pain score pre- and post-Methoxyflurane administration.
• Monitor patient persistently — record full observations every 5 minutes given time-critical inhalation injury status.
• 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.
• Keep patient warm — avoid hypothermia during cooling; cover non-burned areas with dry blanket after cooling is complete.
• Do NOT apply hydrogel dressings in preference over water cooling — water cooling for minimum 20 minutes is preferred.
• 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.
• Scenario ends on arrival of ambulance and IMISTAMBO handover.
• 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