Scenario — Deep burn with suspected inhalation injury — elderly female

advanced Trauma · Elderly · 75yr · female

Patient Information

Dispatch	You are called to the FAP at the Ascot Vale Community Fair. A 75YO female (Margaret Holt) has sustained burns to her right arm and hand after a gas burner flared at a cooking demonstration stall. Bystanders report she was in close proximity to the flame for approximately 15–20 seconds before being pulled clear.
Patient	Margaret Holt — 75yr (60kg)
Incident History	Pt was standing at a cooking demonstration when the gas burner malfunctioned and produced a large sustained flare. She was unable to move away quickly and sustained burns to her right arm (forearm and hand) and lower face/chin area. Bystanders doused the area with water. Pt is alert but distressed. Singed nasal hairs noted by bystanders.
Emergency Contact	David Holt (Son) — 0412 773 490

Initial Rapid Assessment

Response	Alert
Airway	Patent on arrival. Singed nasal hairs visible bilaterally. Mild soot noted around nares and upper lip. No stridor at rest. Patient speaking in full sentences but with a slightly hoarse quality to her voice.
Breathing	Increased work of breathing. Mild accessory muscle use. Pt reports tightness in her chest. RR elevated. SpO2 91% on room air. No audible wheeze or crackles at this time.
Circulation	Radial pulse rapid and regular. Skin of left (unaffected) arm warm and pink with CRT <2s. Right forearm and hand: blistered, moist, red areas (partial-thickness) transitioning to pale, waxy, insensate areas on dorsum of hand (full-thickness). Active weeping from blistered regions.
Disability	GCS 15 (E4V5M6). Alert and orientated to time, place and person. Anxious and in significant pain. Pain score 8/10 to right arm.
Exposure	Burns to right forearm (anterior and posterior surfaces) and right hand (dorsum and fingers). Estimated ~9% TBSA (right forearm ~4.5%, right hand ~2.5%, chin/lower face ~2%). Singed eyebrow hair on right side. No circumferential burns to forearm at this time. Pt is shivering.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	91% (RA)	Mild	22	108	148/88	<2s	15	4 4 ++	36.1	6.8 mmol/L	8
10 mins	97% (O2 NRB 15L/min)	Mild	20	102	144/86	<2s	14	4 4 ++	36.1	6.8 mmol/L	5

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

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.

Facilitator Triggers — if trainees miss a critical step

! (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?')

Treatment Objectives

1. Ensure scene safety — confirm gas burner has been isolated by event staff before approaching patient
2. Don appropriate PPE including gloves
3. Perform Primary Survey: airway assessment with specific attention to inhalation injury indicators — singed nasal hairs, soot around nares, hoarse voice, tachypnoea
4. Identify and document inhalation injury indicators: singed nasal hairs bilaterally, soot around nares, hoarse voice, SpO2 91% on room air, RR 22
5. Apply oxygen via non-rebreather mask (NRB) at 10–15 litres per minute — target SpO2 94–98%
6. Note: carbon monoxide inhalation may produce falsely normal SpO2 readings — maintain high-flow oxygen regardless of SpO2 improvement
7. 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
8. Remove ring from right hand and bracelet from right wrist before oedema develops — document jewellery removed
9. Remove wet or charred clothing from right arm — do NOT remove anything adhered to the wound
10. Perform full burn assessment using Rule of 9s: right forearm ~4.5%, right hand ~2.5%, chin/lower face ~2% — total estimated ~9% TBSA
11. Identify mixed burn depth: blistered moist areas = partial-thickness; pale waxy insensate area on dorsum of right hand = full-thickness
12. Document that the insensate area on the dorsum of the right hand represents full-thickness burn injury
13. After cooling is complete, apply damp sterile dressings to burn areas
14. Administer Methoxyflurane (Penthrox) 3mL via inhaler device for pain — patient self-administers with guidance — indication: moderate-to-severe pain (8/10)
15. 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
16. Perform Vital Sign Survey: GCS, SpO2, RR, HR, BP, BGL, temperature, pain score, CRT
17. Perform Secondary/CNS Survey
18. Record full observations — initial then every 10 minutes (or 5 minutes given airway compromise risk)
19. Monitor closely for signs of progressive airway compromise: increasing hoarseness, stridor, drooling, worsening SpO2, decreasing GCS
20. Recognise that inhalation injury and elderly age place patient at high risk of rapid airway deterioration — early notification of receiving facility is essential
21. Arrange Priority 1 transport to Tertiary Burns Centre — Perth: Fiona Stanley Hospital (FSH) for adult patient aged 75 years
22. 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
23. 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)
24. Scenario ends on arrival of ambulance and IMISTAMBO handover
25. 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

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Signs/Symptoms	Severe pain to right forearm and hand (8/10). Tightness in chest. Hoarse voice. Distress and anxiety. Shivering. Right forearm and hand: mixed partial- and full-thickness burns. Singed nasal hairs. Soot around nares.
Allergies	Penicillin — rash. No known allergy to analgesics.
Medications	Metoprolol 25mg daily (hypertension). Atorvastatin 40mg nocte. Calcium + Vitamin D supplement.
Pertinent History	Known hypertension, well controlled on Metoprolol. No known respiratory conditions. Non-smoker. No prior burns history. Lives independently.
Last Oral Intake	Light lunch approximately 2 hours ago. Small glass of water 30 minutes ago.
Events Leading	Pt was watching a gas-powered cooking demonstration at a community fair stall. The gas burner produced a sudden sustained flare. Pt was unable to move away quickly due to the crowd and sustained burns to her right arm and hand as she raised her arm to shield her face. Her lower face/chin was also exposed.
Treatment Prior	Bystanders poured cold water over burns immediately after incident — cooling ongoing for approximately 5 minutes before EHS arrival. No dressings applied. No analgesia given.

Onset	Approximately 10–15 minutes ago when gas burner flared during cooking demonstration.
Pain	Burning, intense pain to right forearm and blistered areas. Paradoxically, the pale waxy area on the dorsum of her hand is painless — pt unaware of this. Chin area mildly tender.
Quality	Burning and sharp in blistered regions. Absent sensation to dorsum of right hand (full-thickness).
Radiates	Nil radiation. Pain localised to right forearm, hand and chin.
Severity	8/10 to forearm. 0/10 to dorsum of right hand (insensate — full-thickness burn).