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

Area of Science:

• Emergency Medicine
• Anesthesiology
• Prehospital Care

Background:

• Sugammadex is sometimes considered for rescue in prehospital
• cannot intubate, cannot oxygenate
• ,
• (CICO) situations, despite limited evidence.
• Current airway guidelines emphasize front-of-neck access (FONA) as the primary intervention.

Purpose of the Study:

• To critically appraise the evidence for sugammadex as a rescue strategy in prehospital CICO.
• To assess the plausibility of pharmacological reversal modifying outcomes in airway failure.

Main Methods:

• Narrative synthesis of perioperative, emergency department, and prehospital literature.
• Inclusion of case reports, expert consensus, and airway guidelines.

Main Results:

• No outcome-level data support sugammadex effectiveness in established CICO.
• Perioperative CICO cases show reversal does not resolve obstruction or obviate surgical airway.
• Prehospital factors like rapid desaturation limit pharmacological rescue plausibility.

Conclusions:

• Reliance on sugammadex for prehospital CICO is not supported by current evidence.
• Emphasis should be on early CICO recognition, structured algorithms, and timely FONA.
• Pharmacological reversal is not a viable alternative to FONA in CICO.