## **COMMENT Open Access** ![](https://assets.reachrx.ai/images/10.1186%E2%98%8Ds13049-025-01519-8/_page_0_Picture_3.jpeg) # Emergency anaesthetic management in critically ill and injured patients: the STEPS approach (self, team, environment, patient and system) Sarah Morton1,2,3\*, R. Crooks4 , A. Woodman-Bailey5 , C. Reid6 and P. Sherren2,7 ## **Abstract** Contemporary airway management paradigms focus heavily on the anatomical and the technical considerations of 'Difficult Airway' management. Such pervasive language does not always fully capture the critical importance of many other technical and non-technical factors that routinely impact on the safe delivery of emergency anaesthesia in the out-of-theatre environment. The authors believe that it is important to consider the factors beyond anatomy and physiology in emergency anaesthesia (EA) and recommend the following acronym and categories: **S**elf, **T**eam, **E**nvironment, **P**atient (anatomical/physiological) and **S**ystem (**STEPS**). The aim of this mnemonic is to provide a cognitive framework that can be utilised in real-time to better identify the perceived and latent threats surrounding EA that will hopefully encourage a more holistic management approach to airway management in critically ill and injured patients. **Keywords** Anaesthesia, Airway management, Difficult airways, Rapid sequence induction, Critical care, Human factors \*Correspondence: Sarah Morton sarah.morton@doctors.org.uk Imperial College London, London W2 1NY, UK Essex and Herts Air Ambulance Trust, Earls Colne, Colchester CO6 2NS, Essex, UK West Middlesex University Hospital, Chelsea and Westminster NHS Foundation Trust, Twickenham Road, Isleworth TW7 6AF, UK 4 Imperial College NHS Trust, London W2 1NY, UK St George's University Hospital NHS Foundation Trust, Blackshaw Road, London SW17 0QT, UK 6 NSW Ambulance Aeromedical Operations, 33 Nancy Ellis Leebold Drive, Bankstown Airport, NSW 2200, Australia Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK #### **Background** The term "Difficult Airway" has traditionally emphasised anatomical challenges [\[1](#page-3-0)]. However, NAP4 highlighted that many airway complications occur from physiological and environmental factors [\[2\]](#page-3-1). The 2025 Difficult Airway Society (DAS) guidelines discuss the physiologically difficult airway [\[3](#page-3-2)]. The authors believe that it is important to consider the factors beyond anatomy and physiology in emergency anaesthesia (EA) and recommend the following acronym and categories: **S**elf, **T**eam, **E**nvironment, **P**atient (anatomical/physiological) and **S**ystem (**STEPS**) (Fig. [1\)](#page-1-0). ![](https://assets.reachrx.ai/images/10.1186%E2%98%8Ds13049-025-01519-8/_page_0_Picture_20.jpeg) © The Author(s) 2025. **Open Access** This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit [http://creati](http://creativecommons.org/licenses/by-nc-nd/4.0/) [vecommons.org/licenses/by-nc-nd/4.0/.](http://creativecommons.org/licenses/by-nc-nd/4.0/) ![](https://assets.reachrx.ai/images/10.1186%E2%98%8Ds13049-025-01519-8/_page_1_Picture_3.jpeg) **Fig. 1** Self, Team, Environment, Patient and Systems Summary ## **Main text Self (STEPS)** Arguably one of the most influential variables critical to successful EA is the operator tasked with its delivery. However, whilst much attention is given to optimising the patient, little thought is given as to whether the operator themself is in an optimum state. Factors which may pre-dispose a practitioner to sub-optimal performance include: physiological needs; safety and security; love and belonging; self-esteem and self-actualisation [\[4](#page-3-3)]. The real-world application of these include: is the clinician well-rested; fed; emotionally prepared; sufficiently trained and well-supported? Additionally, the performance of EA could be considered a stressful task. Within certain limits, stress can improve performance and be advantageous; however, excessive stress can rapidly lead to detrimental impacts [[5\]](#page-3-4). Stress management requires control of hyperarousal through psychological tools including controlled breathing, positive self-talk ("I've got this") and the visualisation of successful procedural steps. This results in the psychological re-framing of the task as a 'challenge' rather than a 'threat'. Cognitive overloading from multi-tasking must also be avoided. It is imperative to apply the 'Ds' of task overload: Decide to Do (e.g. intubate); Delegate (e.g. someone else can find the PEEP valve); Defer (e.g. "I'll answer your questions later"); or Disregard (e.g. your phone). Referring to cognitive aids such as checklists liberate significant cognitive capacity and encourages priming, as described in the DAS guidelines [[3\]](#page-3-2). Loss of situational awareness and the occurrence of fixation errors may be reduced by clear separation of procedural and team leader roles, as well as pre-agreed triggers for alternative procedural steps pre-briefed to all team members. #### **Team (STEPS)** A team consists of a group of people working together towards a common goal. A team is dependent on a shared mental model of taskwork (what needs to be done) and teamwork (who's going to do it) [\[6](#page-3-5)]. Clear unequivocal communication is required in critical settings and examples included closed loop, standard lexicon, non-mitigating language, and a sterile cockpit (Table [1](#page-2-0)). **Table 1** Communication strategies employed within a team | Communication | Example | | |----------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------|--| | Strategy | | | | Closed loop | "Can you give 100 mg, that's 10 ml of ketamine"
"Okay giving 100 mg, that's 10 ml of ketamine"
"That is correct" | | | Standard lexicon | Confirm, Disregard, Stand by, Unable, Affirmative,
Negative
"Confirm CO2 waveform present and sustained"
"Affirmative CO2 waveform present and sustained" | | | Non-mitigating
language | "Would someone mind giving him a bit of suction
please" (mitigating) versus "Jackie, suction NOW
please" (non-mitigating) | | | Sterile 'cockpit' | "The rocuronium is in can we please have quiet in
the room now" | | #### **Environment (STEPS)** The physical environment in which EA is delivered can influence whether the intervention succeeds. The practitioner should make a rapid assessment to answer two questions: - 1. Does this environment pose an unacceptable risk to myself, my team, or my patient? - 2. What can reasonably be done to optimise it for safe EA delivery? To answer these questions, it is important to consider those factors: - 360-degrees of access to the patient. - Sufficient space for equipment and personnel. - Adequate lighting for task. - Minimal noise which could distract or impaired communication. - Command and control of any crowd. Many of these factors are highlighted in prehospital anaesthesia guidelines, but are equally applicable in hospital settings [\[7](#page-3-6)]. #### **Patient factors (STEPS)** ### *Anatomical considerations* One of the key tenants of EA is to maximise first pass success to at least partly mitigate the risk of adverse events. Clinicians should assess for difficulties with facemask ventilation, supraglottic airway use, and front-ofneck access (FONA) for all EA cases; [[3\]](#page-3-2) this could be a general assessment of potential difficulties if limited time. Prior to induction of EA, it is vital to ensure the following conditions are optimal to plan for any anatomical difficulties: - Patient position and physiology optimised. - A minimum level of equipment provision with standardised setup. - Appropriate monitoring attached. - Environment optimised. - Induction drugs and doses agreed. - Emergency drugs immediately available. - Intubation checklist completed. - Team dynamics optimised and brief undertaken. - FONA techniques and equipment must always be immediately available. While an awake intubation technique may be optimal in a select few cases, execution in critically ill patients can be challenging [\[3](#page-3-2)]. ### *Physiological considerations* One in 25 patients suffering a cardiac arrest typically within the first ten minutes of induction in emergency anaesthesia [[8\]](#page-3-7). Prior to committing to EA in a physiologically compromised patient it is essential to try to optimise the patient's pathophysiology, and aim to understand the underlying aetiology [\[3\]](#page-3-2). Even with the constraints of a critical case, there is almost always time for some concurrent resuscitation before induction, for example the co-administration of fluids. To maximise the safe apnoea period, all patients undergoing EA ideally should have a period of preoxygenation as drugs and equipment are prepared [\[3](#page-3-2)]. Post-intubation, access to an appropriate ventilator is crucial to ensure adequate gas exchange and lung protective ventilation is delivered early. Timely aggressive management of respiratory conditions, such as near-terminal asthma or large pneumothoraces, can also have a significant impact on the margins of safety. Heart rate and arrhythmias should be optimised in line with the European Resuscitation guidelines [[9](#page-3-8)]. Preload requires optimisation but the type, volume and end point for fluid resuscitation is completely dependent on the underlying aetiology. Management of, for example, severe left ventricular dysfunction should be individualised depending on clinical suspicion and bedside echocardiographic findings. Treatment and optimisation with fluids, inopressors and mechanical circulatory support should be delivered as needed and, if possible, occur prior to EA [\[10](#page-3-9)]. Other pathologies such as vasoplegia, aortic stenosis, left ventricular outflow tract obstruction, mitral regurgitation and aortic regurgitation will require special consideration. For neurological pathologies, it is key to address any primary injury and avoid any secondary insults by maintaining normoxia, normocarbia and adequate cerebral perfusion pressure, while concurrently managing any raised intracranial pressure and epileptiform activity. Hyperactive delirium and agitation are often cited as the reason for suboptimal patient preparation during EA, but can have devastating consequences [\[11](#page-3-10)]. Anxiolysis all the way through to procedural sedation may be needed to facilitate optimal patient preparation prior to undertaking EA [\[12](#page-3-11)]. A guideline for the safe transfer of the braininjured patient proposed pragmatic physiological targets for a variety of disease states and is essential reading [\[13](#page-3-12)]. Toxidromes, such as serotonin syndrome, require special consideration. The choice of drugs can be challenging, and clinicians must recognise they can cause harm and therefore individualise drug regimens. Ketamine with its cardiovascular stability is often the drug of choice [\[14](#page-3-13)]. Under-dosing of rocuronium will limit success and therefore doses from 1.5 to 2.0 mg/kg estimated total body weight have been shown to result in significantly fewer cases of inadequate paralysis [\[15\]](#page-3-14). ### **System (STEPS)** Standardisation of training, equipment, and processes reinforced by team simulation—can increase emergency anaesthesia success rates [\[7](#page-3-6)]. Use of checklists has been shown to significantly reduce complications in ICU intubation [\[16](#page-3-15)]. Checklists ensure preparatory steps are taken and equipment readied before induction, while freeing cognitive space and creating a shared mental model for the team. Education should extend beyond practical skills to include reflective practice and shared learning. ## **Conclusions** Contemporary airway management focuses heavily on the anatomical and technical considerations and may not do justice to the broad range of complexities encountered with critically ill and injured patients in the out-of-theatres environment. The authors believe a move to a more holistic terminology with 'Emergency Anaesthesia' is warranted for this challenging patient group. EA, and the use of the STEPS mnemonic, provides a framework that covers both technical and nontechnical factors that can influence the safe delivery of anaesthesia. #### **Abbreviations** EA Emergency anaesthesia DAS Difficult Airway Society #### **Author contributions** PS developed the manuscript concept. All authors were involved in the development, writing and editing of the manuscript. #### **Data availability** No datasets were generated or analysed during the current study. ## **Declarations** #### **Competing interests** The authors declare no competing interests. Received: 18 November 2025 / Accepted: 20 November 2025 #### **References** - 1. Edelman DA, Perkins EJ, Brewster DJ. Difficult airway management algorithms: a directed review. Anaesthesia. 2019;74:1175–85. - 2. Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK: results of the fourth National audit project of the Royal college of anaesthetists and the difficult airway Society. Part 1: anaesthesia. Br J Anaesth. 2011;106:617–31. - 3. Ahmad I, El-Boghdadly K, Iliff H, Dua G, Higgs A, Huntington M, et al. Difficult airway society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults. Br J Anaesth. 2025. 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