Scenario — Paediatric burn trauma with suspected inhalation injury

advanced Trauma · Pediatric · 8yr · female

Patient Information

Dispatch	You are called to the FAP at the Fremantle Community Summer Festival. A 8-year-old female has sustained burns to her arm and chest after a cooking demonstration accident involving a gas burner flare-up. Bystanders state she was standing very close when it ignited. (Amelia Chen, DOB 14/03/2016)
Patient	Amelia Chen — 8yr (25kg)
Incident History	Pt was watching a live cooking demonstration when a gas burner flared unexpectedly. She sustained burns to her right forearm and anterior chest. Bystanders report she was briefly engulfed in the flash flame. She is crying and distressed. Her mother is on scene.
Emergency Contact	Mei Chen (Mother) — 0412 884 231

Initial Rapid Assessment

Response	Alert
Airway	Patent on arrival. Singed nasal hairs visible bilaterally. No audible stridor at rest. Mild hoarseness noted when patient speaks. No soot visible in mouth. Airway patency must be monitored closely — risk of progressive oedema.
Breathing	Increased work of breathing. Tachypnoeic. Accessory muscle use visible. Crying with full sentences but voice hoarse. Mild intercostal recession noted. SpO2 93% on room air.
Circulation	Radial pulse rapid and strong. Skin — right forearm: blistered, red, wet, extremely painful (partial-thickness). Anterior chest: pale, waxy, dry, leathery patch approximately 5% TBSA (full-thickness, reduced sensation). Capillary refill 2 seconds centrally.
Disability	GCS 15 (E4V5M6). Alert and oriented to time, place and person. Extremely distressed and crying. Pupils equal and reactive.
Exposure	Burns identified: right forearm — circumferential partial-thickness approximately 4.5% TBSA; anterior chest — full-thickness patch approximately 5% TBSA. Total estimated TBSA approximately 9–10%. Remainder of body surface intact. Singed eyebrows noted. Clothing removed from burn areas by bystanders prior to EHS arrival.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	93% (RA)	Moderate	26	128	102/68	2s	15	4 4 ++	36.4	5.8 mmol/L	9
10 mins	99% (O2 NRB 15L/min)	Mild	22	118	104/70	2s	15	4 4 ++	36.2	5.8 mmol/L	6

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from paediatric mixed partial-thickness and full-thickness burn trauma to approximately 9–10% TBSA with a suspected inhalation injury based on singed nasal hairs, eyebrow singeing, hoarse voice, and tachypnoea.

Facilitator Triggers — if trainees miss a critical step

! (If trainees do not apply high-flow oxygen via NRB within 2 minutes: Amelia's SpO2 drops to 90% on RA and her work of breathing increases. She begins to show subcostal recession and her voice becomes more strained. Prompt: 'Amelia is looking more tired and her breathing seems harder.')
! (If singed nasal hairs and hoarse voice are not identified or reported: Amelia spontaneously says in a hoarse voice 'my throat feels funny' at 5 minutes. Prompt facilitator to ask trainees: 'What does hoarseness and singed nasal hairs tell you about this patient's airway?')
! (If trainees do not begin cooling the burns within 3 minutes of assessment: Mother asks 'Should we be putting water on it?' Amelia's pain score remains 9/10 and she becomes increasingly distressed and less cooperative.)
! (If trainees fail to note the reduced sensation over the anterior chest full-thickness area and do not document it: Facilitator prompts at 8 minutes — 'Amelia says the chest doesn't hurt much — is that reassuring or concerning? Why?')
! (If trainees attempt to apply creams, butter, or non-sterile materials to burns: Facilitator stops scenario briefly to correct — 'What does the Burn Trauma CPG say about wound dressing?' Only cool water and damp sterile dressings are appropriate.)
! (If trainees do not continuously reassess the airway for progressive oedema: At 12 minutes introduce mild audible stridor — 'Amelia's breathing sounds different now. What do you notice?' This simulates onset of airway oedema and should trigger urgent Priority 1 pre-notification and consideration of backup.)
! (If Methoxyflurane (Penthrox) is considered for analgesia: Facilitator confirms — 'Amelia is 8 years old, 25 kg, alert and cooperative. Is Penthrox appropriate here? Can she self-administer?' Per CPG, Penthrox is authorised for paediatric patients >1 year. Trainees must confirm she can understand and cooperate with the device.)

Treatment Objectives

1. Ensure scene safety — confirm gas burner has been shut off and scene is safe before approaching.
2. Perform Primary Survey with c-spine consideration — mechanism does not suggest spinal injury, no c-spine precautions required.
3. Identify suspected inhalation injury immediately — singed nasal hairs, singed eyebrows, hoarse voice, tachypnoea, and SpO2 93% on RA are RED FLAGS for evolving airway compromise.
4. Apply oxygen via non-rebreather mask (NRB) at 10–15 L/min — target SpO2 ≥95% for paediatric patient. Note: carbon monoxide inhalation may cause falsely normal SpO2 readings; treat clinically.
5. Begin burn cooling immediately — cool burn areas with running water at approximately 15°C for a minimum of 20 minutes. Do NOT use ice, ice water, or butter.
6. Perform burn area assessment using Rule of 9's — right forearm approximately 4.5% TBSA (partial-thickness), anterior chest approximately 5% TBSA (full-thickness). Total estimated 9–10% TBSA.
7. Document time of burn injury — fluid calculations (if performed by Advanced Care) are calculated from time of burn, not EHS arrival.
8. Remove jewellery and clothing unless adhered to wound — check right forearm for any bracelets or tight clothing. Do NOT remove adhered material.
9. Assess depth of burns — right forearm: red, blistered, wet, extremely painful = partial-thickness. Anterior chest: pale, waxy, dry, leathery, reduced sensation = full-thickness. Document both.
10. Identify and document reduced sensation over anterior chest — reduced pain over full-thickness burns is expected and should not be mistaken for the patient being less seriously injured in that area.
11. Administer Methoxyflurane (Penthrox) 3 mL via inhaler for analgesia — Amelia is 8 years old, 25 kg, alert, oriented, and able to cooperate. Paediatric dose: 3 mL inhaled intermittently. Confirm patient understanding of device. Monitor for over-sedation.
12. Apply damp sterile dressings to burn areas after minimum 20 minutes of cooling — do not apply dry dressings directly to burns. Do not apply creams, gels, or non-sterile materials.
13. Perform Vital Sign Survey — GCS, SpO2, RR, HR, BP, BGL, temperature, pain score, PERL.
14. Continuously monitor airway — reassess for stridor, increasing hoarseness, increased work of breathing, or drooling every 2–3 minutes. These indicate progressive airway oedema and are a time-critical emergency.
15. Perform Secondary / CNS Survey — assess for other injuries from the flash flame (eyes, other body surface areas).
16. Administer Ondansetron 4 mg oral wafer for nausea and vomiting prophylaxis (spinal/eye injuries indication is not applicable here; if patient vomits or has moderate to severe nausea this is an authorised indication) — Amelia is >4 years and >15 kg. Do not repeat paediatric dose.
17. Record full observations every 10 minutes — or every 5 minutes given time-critical presentation.
18. Pre-notify receiving facility (Perth Children's Hospital — paediatric burns tertiary centre, patients 15 years and under) — patient has >5% TBSA paediatric burns, airway burns suspected, Priority 1 transport indicated.
19. Keep patient warm — avoid hypothermia during cooling. Cover cooled areas with damp sterile dressings and cover remainder of patient with a blanket after cooling phase.
20. Reassure Amelia and her mother continuously throughout the scenario — child is distressed, keep communication calm, age-appropriate, and include the parent.
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 · Dyspnoea & Respiratory Distress · Oxygen Delivery · Methoxyflurane (Penthrox) · Ondansetron · Primary Survey · Secondary & CNS Survey · Bag Valve Mask Ventilation · Pain Assessment · Penthrox Inhaler Administration · Minor Wound Management

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Signs/Symptoms	Severe burning pain right forearm. Chest burn noted but less painful — patient reports 'it feels numb there'. Hoarse voice. Mild shortness of breath. Distressed and tearful.
Allergies	NKDA — no known drug allergies.
Medications	Nil regular medications.
Pertinent History	No prior burns history. No respiratory conditions. Born at term, no significant medical history. Mother confirms immunisations up to date.
Last Oral Intake	Ate a sausage roll approximately 45 minutes ago. Water approximately 20 minutes ago.
Events Leading	Amelia was standing at the front of a crowd watching a cooking demonstration. The gas burner flared unexpectedly when the demonstrator added oil, producing a brief large flash flame. Amelia was standing approximately 0.5 metres from the burner. She was not knocked over.
Treatment Prior	Bystanders removed clothing over burn areas. No water cooling applied prior to EHS arrival. Mother applied no creams or substances.

Onset	Acute — approximately 12 minutes ago at time of EHS arrival.
Pain	Right forearm — severe, burning, constant. 9/10. Anterior chest — significantly reduced sensation, patient describes it as 'weird, not as sore as the arm'.
Quality	Right forearm — sharp, intense burning. Anterior chest — reduced sensitivity consistent with full-thickness injury.
Radiates	Nil radiation of pain.
Severity	9/10 right forearm. 2/10 anterior chest (reduced sensation — full-thickness).