Simulated Patient Scenario

Adult Burn Victim

Scenario Details

Scenario: Adult Thermal Burns - House Fire

Simulated Patient: 45-year-old Male

Actor/Actress: Student Actor (Patient), Bystander/Neighbour

MDT Information

Urgent Response - Structure Fire / Person Injured
Reports of house fire, possible person trapped, now extricated
Patient conscious, reported burns
Fire services on scene / en route
Location: Residential address

On Arrival

You arrive at a single-story house with smoke still emanating from windows. Firefighters are present. A neighbour directs you to the front lawn where the patient, a 45-year-old male, is lying supine. He has been moved away from the immediate fire scene. He is conscious, moaning in pain, and has obvious burns to his face, neck, chest, and both arms. His clothing appears partially burned and singed. He has soot around his nose and mouth, and his voice sounds hoarse.

Scene Safety Note: Ensure scene is safe, liaise with fire command regarding hazards before approaching patient.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Critically unwell adult, extensive burns, potential airway compromise, severe pain.
Response	Opens eyes to voice, moaning, appears confused/agitated. (AVPU = V / Confused)
Airway	Hoarse voice, soot around nose/mouth, facial/neck burns. High risk of airway obstruction. Possible stridor developing.
Breathing	Rapid, shallow respirations. Possible difficulty with chest expansion due to circumferential burns (assess later).
Circulation	Skin appears burned/damaged on exposed areas. Tachycardic. Peripheral pulses may be difficult to assess due to burns/swelling.
Disability	Altered mental state (agitated/confused - GCS approx 13-14: E3, V4-5, M6). Assess for associated trauma.
Exposure/Environment	Outdoor lawn. Patient exposed to elements. Need to remove burning/smoldering clothing, prevent heat loss.

Secondary Survey and Simulation Progression

History (obtained from patient - difficult, and bystander/firefighters)

Allergies	NKDA (Patient unable to confirm reliably)
Medications	Unknown.
Past Medical History	Unknown.
Last Oral Intake	Unknown.
Events Preceding	Firefighters report finding patient in smoke-filled room near the origin of the fire (believed to be kitchen). Patient was conscious but disoriented when extricated ~5-10 minutes ago. Duration of entrapment unknown. Mechanism involves thermal burns and potential smoke inhalation.

Vital Signs/Assessment (Initial)

Parameter	Value
Resp. Rate (/min.)	28 (Shallow)
Lung Sounds (L/R)	May be difficult to assess due to noise/pain. Possible wheeze/crackles developing (inhalation injury).
SpO2 (%)	90% (On room air initially - May be falsely high if CO poisoning present)
EtCO2 (mmHg)	30 mmHg (Low initially due to tachypnoea)
Pulse Rate (/min.)	125, regular
CRT (sec.)	3 sec
ECG rhythm	Sinus Tachycardia
12-lead ECG	Sinus Tachycardia. Rule out ischaemia (stress/hypoxia).
BP (mmHg)	100/65 (May be initially maintained then drop)
Skin	Burned areas as described. Unburned skin pale, possibly clammy.
Pain (/10)	Severe pain reported (patient moaning, agitated). Difficult to quantify.
GCS (/15: E,V,M)	13/15 (E3, V4 - confused, M6 - obeys) - Monitor closely for deterioration.
BGL (mmol/L)	8.5 (Stress hyperglycaemia common).
Pupils (mmL/mmR)	Equal and Reactive (PERL).
Temp. (°C)	Difficult to assess accurately, risk of hypothermia.

Physical Examination

General Appearance: Acutely unwell, lethargic, pale, profoundly weak.
Airway: Facial/neck burns, singed nasal hairs, soot in mouth/nose, hoarse voice, brassy cough, potential stridor. High risk of imminent airway obstruction.
Breathing: Tachypnoea, shallow effort. Assess chest wall movement - risk of restriction from circumferential torso burns. Auscultate lungs for wheeze, crackles (inhalation injury).
Circulation: Assess extent and depth of burns. Use Rule of Nines for TBSA estimation (e.g., Face/Neck ~9%, Anterior Chest ~9%, Full Ant Arm ~4.5%, Full Post Arm ~4.5% = ~27% TBSA - adjust based on visual). Burns appear mixed depth (superficial partial to deep partial/full thickness - red, blistering, possibly white/leathery areas). Check peripheral pulses, especially in circumferentially burned limbs.
Disability: Monitor GCS. Assess for associated traumatic injuries from fall/collapse during fire.
Exposure: Remove all clothing/jewellery carefully (cut around areas stuck to burns). Keep patient warm.

Assessment and Treatment

Appropriate Management Focus

Safety & Stop Burning: Ensure scene safe. Remove patient from source. Extinguish any smoldering clothing/debris. Remove non-adherent clothing and jewellery.
Airway Management: Highest priority. Recognize signs of airway burns/inhalation injury. Prepare for definitive airway management (intubation) if signs of obstruction develop or are anticipated based on mechanism/findings. Provide high-flow oxygen via NRB mask initially. Early senior paramedic/critical care backup essential.
Breathing Support: Maintain high-flow oxygen (humidified if possible). Monitor SpO2 (aware of potential CO interference). Monitor respiratory rate, effort, lung sounds, EtCO2. Assist ventilations if necessary. Consider escharotomy need for circumferential chest burns (hospital procedure).
Circulation - Fluid Resuscitation: Establish large-bore IV access (x2 if possible) through unburned skin where feasible. Commence IV fluid resuscitation using Parkland formula (or similar local protocol) as a guide: Volume (mL) = TBSA (%) x Weight (kg) x 4mL. Give half over first 8 hours (from time of burn). Titrate to vital signs and urine output (hospital). Start infusion promptly.
Burn Cooling: Cool burns with cool running water (ideally 15-20°C) for up to 20 minutes if within 3 hours of injury AND logistically feasible. Focus on cooling the burn, not the patient. Stop if patient becomes hypothermic. Avoid ice.
Burn Covering: Cover cooled burns with sterile, non-adherent dressings (e.g., cling film - applied longitudinally, not circumferentially; specialised burn dressings).
Pain Management: Provide aggressive IV opioid analgesia (e.g., Morphine or Fentanyl titrated doses). Burns are extremely painful.
Temperature Management: Prevent hypothermia. Keep patient covered with blankets after cooling/dressing. Monitor temperature if possible.
Consider Carbon Monoxide/Cyanide: High index of suspicion in enclosed space fires. Maintain high-flow oxygen. Specific antidotes (hospital based).
Transport: Urgent transport to a designated Burns Centre/Unit is required. Pre-notify early with detailed information (mechanism, TBSA%, depth, airway status, vitals, treatments).
Teamwork & Communication: Coordinate with fire services. Clear roles within team (airway, IV/fluids, dressings). Communicate calmly with patient. Detailed handover.

Debrief Focus Points

Scene safety in fire incidents.
Recognizing signs of airway burns and inhalation injury - prioritizing airway management.
Principles of burn assessment (TBSA estimation - Rule of Nines, depth assessment).
Burn management priorities: Stop burning, ABCDE, Cooling, Covering, Fluids, Analgesia, Warmth.
Fluid resuscitation in burns (Parkland formula application).
Appropriate burn cooling techniques and duration.
Pain management strategies in burn patients.
Preventing and managing hypothermia.
Considering associated injuries (trauma, CO/cyanide poisoning).
Importance of transport to a specialised Burns Unit and effective pre-notification.