When Reversal Is Not Rescue: The Prehospital Sugammadex Myth in Airway Management

Abstract

Evidence supporting the use of sugammadex as a rescue strategy in prehospital “cannot intubate, cannot oxygenate” (CICO) situations remains sparse and indirect. Although contemporary airway guidelines prioritize front-of-neck access (FONA) as the definitive intervention, discussion of pharmacological reversal persists in prehospital practice, predominantly within gray literature, local protocols, and educational materials. This persistence reflects an ongoing hypothesis in prehospital airway management that warrants critical appraisal.

We performed a narrative synthesis of perioperative, emergency department, and prehospital literature, including case reports, expert consensus documents, and contemporary airway guidelines, to assess whether pharmacological reversal can plausibly modify outcomes in airway failure. Across these sources, no outcome-level data support sugammadex as an effective rescue maneuver in established CICO. Perioperative CICO case series further indicate that reversal of neuromuscular blockade does not reliably resolve airway obstruction or obviate the need for surgical airway access.

In the prehospital environment, rapid desaturation and limited monitoring further reduce the plausibility of pharmacological rescue once CICO has developed. For helicopter and ground emergency medical service systems, current evidence supports emphasis on early recognition of CICO, structured airway algorithms, and timely performance of FONA, rather than reliance on pharmacological reversal.