((If inhalation injury signs — singed nasal hairs, hoarse voice, soot around nares — are not identified and documented within the first 3 minutes, the patient's voice becomes markedly hoarser, RR increases to 26, and SpO2 drops to 88% on room air. Patient states: 'My throat feels like it's closing up.'))

((If high-flow oxygen via non-rebreather mask is not applied promptly, SpO2 remains at 91% or drops further to 88%. Patient becomes more anxious and confused — GCS drops to 13 (E3V4M6).))

((If cooling is not continued for a minimum of 20 minutes total from time of burn — accounting for the 5 minutes already done by bystanders — patient's pain score remains at 8/10 and the facilitator informs trainees that partial-thickness areas are at increased risk of progression to full-thickness injury.))

((If the painless full-thickness area on the dorsum of the right hand is not identified and specifically documented, the facilitator prompts: 'You notice the patient says her right hand doesn't hurt at all — what does this tell you about the depth of the burn here?'))

((If the patient is not protected from further heat loss — she is shivering and wet from bystander water cooling — the facilitator states her temperature has dropped to 35.4°C and shivering has increased. Ask trainees: 'What is your priority now — continuing to cool the burns or preventing hypothermia?'))

((If jewellery — patient is wearing a silver ring on right hand and a bracelet on right wrist — is not removed before oedema develops, the facilitator reminds trainees: 'The patient's hand is beginning to swell — what have you forgotten?'))

((If trainees attempt to apply a circumferential bandage tightly around the right hand or forearm, the facilitator notes: 'Oedema is developing — how will a tight bandage affect distal circulation?'))

This patient is suffering from mixed partial-thickness and full-thickness burns to the right forearm, hand and lower face (~9% TBSA), with suspected inhalation injury evidenced by singed nasal hairs, soot around nares, hoarse voice, and tachypnoea with reduced SpO2 on room air.

• Ensure scene safety — confirm gas burner has been isolated by event staff before approaching patient
• Don appropriate PPE including gloves
• Perform Primary Survey: airway assessment with specific attention to inhalation injury indicators — singed nasal hairs, soot around nares, hoarse voice, tachypnoea
• Identify and document inhalation injury indicators: singed nasal hairs bilaterally, soot around nares, hoarse voice, SpO2 91% on room air, RR 22
• Apply oxygen via non-rebreather mask (NRB) at 10–15 litres per minute — target SpO2 94–98%
• Note: carbon monoxide inhalation may produce falsely normal SpO2 readings — maintain high-flow oxygen regardless of SpO2 improvement
• Continue cooling of burn areas with cool running water (approximately 15°C) for a minimum of 20 minutes total — account for 5 minutes of bystander cooling already performed, therefore continue for at least 15 minutes further
• Remove ring from right hand and bracelet from right wrist before oedema develops — document jewellery removed
• Remove wet or charred clothing from right arm — do NOT remove anything adhered to the wound
• Perform full burn assessment using Rule of 9s: right forearm ~4.5%, right hand ~2.5%, chin/lower face ~2% — total estimated ~9% TBSA
• Identify mixed burn depth: blistered moist areas = partial-thickness; pale waxy insensate area on dorsum of right hand = full-thickness
• Document that the insensate area on the dorsum of the right hand represents full-thickness burn injury
• After cooling is complete, apply damp sterile dressings to burn areas
• Administer Methoxyflurane (Penthrox) 3mL via inhaler device for pain — patient self-administers with guidance — indication: moderate-to-severe pain (8/10)
• Prevent hypothermia: cover non-burned areas with dry blanket — do NOT cover burned areas until dressings applied; balance cooling requirement against hypothermia risk especially given patient is elderly and already shivering
• Perform Vital Sign Survey: GCS, SpO2, RR, HR, BP, BGL, temperature, pain score, CRT
• Perform Secondary/CNS Survey
• Record full observations — initial then every 10 minutes (or 5 minutes given airway compromise risk)
• Monitor closely for signs of progressive airway compromise: increasing hoarseness, stridor, drooling, worsening SpO2, decreasing GCS
• Recognise that inhalation injury and elderly age place patient at high risk of rapid airway deterioration — early notification of receiving facility is essential
• Arrange Priority 1 transport to Tertiary Burns Centre — Perth: Fiona Stanley Hospital (FSH) for adult patient aged 75 years
• Pre-notify receiving facility with IMISTAMBO handover including: suspected inhalation injury, mixed partial- and full-thickness burns ~9% TBSA, hoarse voice, SpO2 on NRB, age and weight
• Consider direct transfer to Fiona Stanley Hospital (FSH) given: airway burns suspected, burns to face, ~9% TBSA adult (above 15% threshold for IV fluid indication but IV fluid is outside EHS scope — ensure early handover for fluid resuscitation)
• Scenario ends on arrival of ambulance and IMISTAMBO handover
• Attention to hand hygiene will be given throughout the scenario.

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