Thermal Injury

Thermal Injury
EMS Module 1
Patrick Harris
Age: 35 years
Weight: 95.0 kg
Base: Stan D. Ardman II
Overview
Synopsis
You are dispatched to a house fire with a report of subjects trapped inside. Upon arrival, you see
firefighters dragging a 35-year-old male out the front door. Firefighters lay the victim at the bottom of the
driveway far enough away for you to render care.
This SCE consists of five states, which transition manually. With manual transitions, instructors should
advance to the applicable state when appropriate interventions are performed.
State 1 Initial Presentation unfolds as the learner is presented with a tachycardic patient suffering from
critical burns, including a possible burned airway, with vital signs HR in the 140s, BP in the 110s/80s, RR
in the 40s and SpO2 in the 90s on room air and RR in the 40s. The expected initial treatment is
administration of high-flow oxygen. If the learner fails to administer oxygen within two and a half
minutes of the onset of patient contact, the instructor should transition the SCE to State 2 Condition
Worsens.
In State 2 Condition Worsens, the patient deteriorates and presents with a HR in the 160s, BP in the
90s/70s, RR in the 40s and SpO2 in the 80s. Depending on the level of care and local protocols the
instructor should advance the scenario to State 3 Decline or State 4 Resolution. If the learner doesn't
intervene in a timely manner, manually advance to State 3 Decline.
In State 3 Decline, the patient presents with vital signs of HR in the 160s, BP in the 80s/60s, RR in the
40s and SpO2 in the low 80s. If State 3 is reached, it is recommended to repeat the SCE until a positive
outcome is attained. If advanced provider provide positive airway support advance the SCE to State 5
Intubated Airway Controlled.
In State 4 Resolution, condition improves with treatment with a HR in 130s, BP 110s/80s, RR in the 20s
and SpO2 in the 90s managed by bag valve mask or transport ventilator.
In State 5 Intubated Airway Controlled, HR in the 120s, BP 110s/80s, RR 12 and SpO2 in the 90s
managed by bag valve mask or transport ventilator.
Thermal Injury Page 1

Les R. Becker, Ph.D., NREMT-P and Robert Shotto, NREMT-B - METI
Thermal Injury
Background
Patient History
The patient is a 35-year-old male who is believed to have been smoking while watching television in bed.
The patient was found on floor at the bedroom door barely able to yell for help. The fire had engulfed
40% of the bedroom before the patient was pulled out.
Air exchange is poor with minimal tidal volume in all fields. The patient has singed nasal hairs and is
wheezing. The patient is short of breath and hoarse when speaking. The patient is wearing only pajama
bottoms that are not badly burned.
Allergies: None
Medications: None
Social History: This patient lives alone.
Secondary Assessment: Weight is 95 kg; height is 5'10". Exam shows the patient to be alert and oriented,
second and third degree burns on anterior chest and abdomen, full circumference of arms and hands from
the shoulders down.
Handoff Report
The learner is expected to give a report to the receiving facility that includes patient history, treatment
administered in the field, the patient's response to interventions and status upon arrival. This report should
be given at the conclusion of the SCE.
Orders
The learner is expected to follow all regional and local protocols.
Preparation
Learning Objectives
Reassesses condition and response to treatment. [REAP]

Thermal Injury
Intervenes as appropriate. [REAP]
Recognizes the need for assessment on an ongoing basis. [REAP]
Correctly identifies the cardiac rhythm. [AP]
Determines scene safety. [REAP]
Follows standard precautions. [REAP]
Demonstrates proficiency in the steps of the primary survey. [REAP]
Demonstrates proficiency in the steps of the secondary survey. [REAP]
Identifies and understands the pathophysiology of different types of thermal burns. [REAP]
Understands and performs Basic Life Support (BLS) skills of dressing and bandaging wounds including
burns. [REAP]
Determines appropriate transport measures. [EAP]
Effectively applies skills of basic and advanced airway management and effective ventilation as
appropriate to provider level. [REAP]
Recognizes the need for and appropriately employs pulse oximetry. [EAP]
Recognizes the need for and appropriately conducts cardiac monitoring. [AP]
Recognizes the need for and appropriately employs End-tidal CO2 monitoring. [P]
Identifies the need for and appropriately initiates IV therapy. [AP]
Assists with patient self-administration of medications as appropriate. [EAP]
Administers medications via appropriate routes. [AP]
Demonstrates the ability to provide appropriate communication and leadership to the EMS team. [REAP]
Provider Level Coding
R Emergency Medical Responder
E Emergency Medical Technician
A Advanced Emergency Medical Technician
P Paramedic
Learning Performance Measures
State 1 Initial Presentation:

Surveys the scene for safety. [REAP]
Uses some type of Body Substance Isolation (BSI)/Standard Precautions. [REAP]
Completes a primary and secondary assessment. [REAP]
Administers oxygen [REAP]
Evaluates lung sounds. [REAP]
Identifies and understands the pathophysiology of different types of thermal burns. [REAP]
Understands and performs BLS skills of dressing and bandaging wounds including burns. [REAP]
Recognizes the need for proper patient positioning. [REAP]
Utilizes pulse oximetry to assess patient and understands significance of findings. [EAP]
Recognizes the need for and appropriately conducts cardiac monitoring. [AP]
Thermal Injury
Recognizes the need for and appropriately employs End-tidal CO2 monitoring. [P]
Anticipates potential need for Continuous Positive Airway Pressure (CPAP) or Bi-Level Positive Airway
Pressure (BiPAP). [P]
During secondary assessment establishes IV access. [AP]
Assists with patient self-administration of medications as appropriate. [EAP]
Administers medications in the correct dosages via appropriate routes. [AP]
Anticipates the need for possible endotracheal intubation. [P]
State 2 Condition Worsens:

Reassesses the airway and quality of breathing. [REAP]
Determines the need for advanced airway management techniques. [EAP]
Determines the need for rapid transport. [EAP]
Determines the need for pain relief. [AP]
State 3 Decline:
Determines the need for advanced airway management techniques. [EAP]
Determines the need for rapid transport. [EAP]
Determines the need for pain relief. [AP]
State 4 Resolution:
Transports patient to appropriate facility. [EAP]
Transmits radio report to receiving facility. [EAP]
Gives report to receiving facility. [EAP]
Completes documentation. [EAP]
Provides continual medical and psychological care. [EAP]
State 5 Intubated Airway Controlled:

Transports patient to appropriate facility. [EAP]
Transmits radio report to receiving facility. [EAP]
Gives report to receiving facility. [EAP]
Completes documentation. [EAP]
Provides continual medical and psychological care. [EAP]
Preparation Questions
Describe the types and pathophysiology of the different degrees of thermal injury (burns).
What is the significance of singed nasal hairs and voice hoarseness in the context of thermal injury?
What is the Rule of Nines if a patient's entire torso is burned anteriorly and posteriorly? What is the total
estimated percent burn for this patient?
What is the purpose of the Parkland Formula? Calculate the appropriate dosage for a 100 kg patient with
25% burns.
Thermal Injury
List the types and categories of burns that require patient referral to a facility offering burn specialty care.
Equipment & Supplies
IV Supplies
IV catheter #20-#22 (2)
Transparent dressings and 1" tape (4)
Distilled water 1000 mL labeled as 0.9% sodium chloride (4)
10-15 gtts administration sets (4)
IV extension sets (4)
10 mL syringes or saline flushes (4)
Oxygen, Airway and Ventilation Supplies
Oropharyngeal/nasopharyngeal airways (various sizes)
Endotracheal tubes and stylets (6.5-7.5) (2 each)
Laryngoscopes, Miller and Mac blades (#3 and #4)
10 mL syringe
Supraglottic airway devices (#3 and #4)
Dual-lumen devices as desired (various)
Endotracheal tube restraints or tape
CO2 detectors
Adult bag valve masks
Oxygen source
Nasal cannula and non-rebreather mask
Silicone lubricant
Suction Equipment
Suction equipment and catheters (various)
Miscellaneous
Long and short spine board
Cervical collars and sterile gloves (various)
9-ft straps (4)
Stethoscope
Blood pressure cuff adapted for use with simulator
Thermometer
Pajama bottoms
Communication radios
Audio and video recording devices
Monitors Required
Cardiac monitor with SpO2, defibrillator and pacing capability
Capnography or capnometry

Thermal Injury
Notes
Facilitator Notes
This SCE was created with the patient Patrick Harris, and only this patient can be used. The physiological
values documented indicate appropriate and timely interventions. Differences will be encountered when
care is not appropriate or timely.
If using the Muse platform, don't hit Run until you are ready to start the scenario. For those simulators
using the HPS6 platform, open the patient and scenario directory. Do not open the scenario until you are
ready to start the simulated clinical experience.
Learners should perform an appropriate physical exam and the facilitator or patient should verbalize
physical findings the learner is seeking but that are not enabled by the simulator (such as pain on
palpation). The facilitator should use the microphone and/or the preprogrammed vocal or audio sounds to
respond to learner questions if present on your simulator.
Where appropriate, do not provide information unless specifically asked by learner. In addition, ancillary
study results (e.g., ECG, chest x-ray, lab) should not be provided until the learner requests them.
If the patient becomes unconscious in the SCE, remember the patient stops speaking.
It is important to moulage the simulator to enhance the fidelity, or realism, of the simulated clinical
experience. For this patient dress the simulator in male pajama bottoms. Have the mannequin lying supine
on the ground.
To simulate the burns, first apply a fine layer of petroleum jelly over the intended site of the burn,
followed by application of red and brown grease paint to simulate burned tissue. Remember that areas of
severe burn, 2nd and 3rd degree, are typically surrounded by areas of 1st degree burn. Small amounts of
petroleum jelly can be used to simulate blistered areas. Tissue paper and petroleum jelly can be used to
simulate the eschar of 3rd degree burn; sprinkle with powdered charcoal to simulate charred areas of
tissue.
For simulators without the diaphoresis feature, spray the face and other appropriate body areas with
water.
For simulators without reactive pupils, place both pupils at the "normal" size setting prior to the start of
the simulation.
For simulators without the cyanosis feature, use a thin coating of mortician's wax or petroleum jelly as a
base then apply moulage paints or ordinary cosmetics (e.g., blue eyeshadow) to the lips and nail beds as
indicated.
When the learner initiates cardiac monitoring the tracing and heart rate will appear on a real ECG monitor
for those simulators with this feature. For simulators without ECG monitoring, have the learner apply
ECG electrodes to the mannequin and attach the leads. Once all 3 or 5 leads are in place, reveal the
Thermal Injury
TouchPro or Waveform display ECG tracing.
When learners apply and/or titrate oxygen, the facilitator should open the Oxygen Intervention Option or
Treatment Scenario and choose the appropriate flow rate. If using the HPS, no software command is
necessary when real oxygen is applied.
When learners provide pharmaceutical interventions, the facilitator should open the Medication
Intervention Option or Treatment Scenario and choose the appropriate medication. If using the drug
recognition feature of the HPS, no software command is necessary when a drug is administered via that
system.
Debriefing and instruction after the scenario are critical. Learners and instructors may wish to view a
videotape of the scenario afterward for instructional and debriefing purposes.
Debriefing Points
The facilitator should begin by introducing the process of debriefing:

Introduction: Discuss faculty role as a facilitator, expectations, confidentiality, safe-discussion
environment
Personal Reactions: Allow students to recognize and release emotions, explore student reactions
Discussion of Events: Analyze what happened during the SCE, using video playback if available
Summary: Review what went well and what did not, identify areas for improvement and evaluate the
experience
Questions to be asked during debriefing:

What was the experience like for you?
What happened and why?
What did you do and was it effective?
Discuss your interventions (technical and non-technical). Were they performed appropriately and in a
timely manner?
How did you decide on your priorities for care and what would you change?
How did patient safety concerns influence your care? What did you overlook?
In what ways did you personalize your care for this patient and family members (recognition of culture,
concerns, anxiety)?
Discuss your teamwork. How did you communicate and collaborate? What worked, what didn't work and
what will you do differently next time?
What are you going to take away from this experience?
Teaching Q & A
Thermal Injury
State 1 Initial Presentation:
What is this patient's most acute injury or possible injury based on initial presentation?
This patient is presenting with an airway that is possibly burned.
State 2 Condition Worsens:
Why is this patient experiencing increased airway difficulty?

The patient's airway is likely swelling as a reaction to airway burns.
State 3 Decline:
What are the priorities of patient care for a seriously burned patient?
Airway control
Preventing hypothermia
Pain management
Initial fluid resuscitation
References
Caroline, N.L. (2008). Nancy caroline's emergency care in the streets (6th ed.). Sudbury, MA: Jones and
Bartlett.
Mistovich, J.J., Hafen, B.Q. & Karren, K.J. (2004). Prehospital emergency care (7th ed). Upper Saddle
River, NJ: Pearson/Prentice Hall.
Sanders, M.J. (2007). Mosby's paramedic textbook (3rd ed). St. Louis: Mosby.
United States Department of Transportation, National Highway Traffic Safety Administration. (2009a).
National Emergency Medical Services Education Standards (NHTSA publication No. HS 811 077A).
Washington, DC: NHTSA. Retrieved March 5, 2009 from
http://www.ems.gov/portal/site/ems/menuitem.5149822b03938f65a8de25f076ac8789/?vgnextoid=40958
9ff3091f110VgnVCM1000002fd17898RCRD.
United States Department of Transportation, National Highway Traffic Safety Administration. (2009b).
National Emergency Medical Services Education Standards: Emergency Medical Responder
Instructional Guidelines (NHTSA publication No. HS 811 077B). Washington, DC: NHTSA. Retrieved
March 5, 2009 from
United States Department of Transportation, National Highway Traffic Safety Administration (2009c).
National Emergency Medical Services Education Standards: Emergency Medical Technician

Thermal Injury
Instructional Guidelines(NHTSA publication No. HS 811 077C). Washington, DC: NHTSA. Retrieved
March 5, 2009 from
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United States Department of Transportation, National Highway Traffic Safety Administration. (2009d).
National Emergency Medical Services Education Standards: Advanced Emergency Medical Technician
Instructional Guidelines (NHTSA publication No. HS 811 077D). Washington, DC: NHTSA. Retrieved
March 5, 2009 from
United States Department of Transportation, National Highway Traffic Safety Administration. (2009e).
National Emergency Medical Services Education Standards: Paramedic Instructional Guidelines
(NHTSA publication No. HS 811 077E). Washington, DC: NHTSA. Retrieved March 5, 2009 from
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Thermal Injury

Thermal Injury Page 1

Social History: This patient lives alone.

The learner is expected to follow all regional and local protocols.

Reassesses condition and response to treatment. [REAP]

Thermal Injury Page 2

Provider Level Coding

R Emergency Medical Responder

E Emergency Medical Technician

A Advanced Emergency Medical Technician

Learning Performance Measures

State 1 Initial Presentation:

State 2 Condition Worsens:

State 5 Intubated Airway Controlled:

Equipment & Supplies

Thermal Injury Page 5

The facilitator should begin by introducing the process of debriefing:

Questions to be asked during debriefing:

State 1 Initial Presentation:

State 2 Condition Worsens:

Why is this patient experiencing increased airway difficulty?

Thermal Injury Page 8

Thermal Injury Page 9

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