What is the recommended dose of methylprednisolone sodium succinate (MPSS) for a patient with a hanging injury?

Methylprednisolone Sodium Succinate (MPSS) is NOT Recommended for Hanging Injuries

There is no evidence supporting the use of MPSS for hanging injuries, and current guidelines explicitly recommend against routine MPSS administration for traumatic spinal cord injury, which would be the only potential indication in this context.

Why MPSS Should Not Be Used in Hanging Injuries

Lack of Evidence for Hanging-Specific Injuries

• Hanging injuries involve a complex combination of hypoxic-ischemic brain injury, potential cervical spine trauma, and airway compromise—none of which have established benefit from corticosteroid therapy 1
• The mechanism of injury in hanging (primarily hypoxic and vascular) differs fundamentally from the mechanical spinal cord compression that MPSS was studied for 2, 3

Current Guidelines Recommend Against Routine MPSS Use

• The Congress of Neurological Surgeons (2019) found no studies meeting inclusion criteria to support MPSS use in thoracolumbar spine trauma 1
• French guidelines (2020) explicitly state: "After post-traumatic spinal cord injury, it is not recommended to administrate steroids early on to improve the neurological prognosis" (GRADE 1, Strong Agreement) 1
• The AANS/CNS classify MPSS as only an "option" rather than a standard recommendation, reflecting the controversial nature of its use even in pure spinal cord injury 1

The Controversial NASCIS Data

• Even in acute traumatic spinal cord injury (the only studied indication), MPSS showed only modest motor score improvements when given within 8 hours, with no functional outcome benefits 2, 3, 4
• The NASCIS trials used post-hoc analysis, had methodological flaws, and included many patients with mild or no motor deficits, artificially inflating apparent benefits 1
• A 2017 clinical practice guideline suggests MPSS only as a "treatment option" (weak recommendation) within 8 hours of acute SCI, not as standard care 4

Critical Pitfalls to Avoid

Misapplication of Spinal Cord Injury Protocols

• Hanging injuries are NOT equivalent to isolated traumatic spinal cord injuries—the primary pathology is hypoxic-ischemic, not mechanical compression 1
• Even if cervical spine injury is present, the hypoxic component dominates the clinical picture and prognosis

Potential Harm Without Benefit

• MPSS carries significant risks including infection (7% vs 3% in controls), gastrointestinal complications, and metabolic derangements 1
• The NASCIS trials showed higher complication rates in steroid-treated groups, particularly with prolonged (48-hour) infusions 2, 3
• In hanging injuries, where infection risk is already elevated due to aspiration and prolonged intubation, adding MPSS increases morbidity without proven benefit 1

What Should Be Done Instead

Focus on Established Interventions

• Immediate airway management and ventilatory support
• Hemodynamic stabilization with mean arterial pressure targets of 70-85 mmHg if spinal cord injury is confirmed (though evidence for MAP >70 mmHg is limited) 1
• Urgent cervical spine imaging (CT followed by MRI if neurological deficits are unexplained) 1
• Neuroprotective measures for hypoxic-ischemic brain injury (targeted temperature management if indicated by institutional protocols)

If Spinal Cord Injury is Documented

• Even with confirmed acute traumatic spinal cord injury, the decision to use MPSS should be made only after informed discussion about its limited benefits and risks 4
• If MPSS is considered (within 8 hours of injury only): 30 mg/kg IV bolus over 15 minutes, followed by 5.4 mg/kg/hour for 23 hours 5, 2, 4
• Do NOT extend infusion to 48 hours—this increases complications without additional benefit 4

Documentation is Essential

• If a conscious patient can communicate, they should be informed of the limited evidence and given the opportunity to decline MPSS 6
• Document the rationale for any decision regarding MPSS administration, as this remains a medicolegal area of controversy 1

In summary: MPSS has no role in the routine management of hanging injuries. Focus on airway, oxygenation, hemodynamics, and neuroprotective care for hypoxic-ischemic injury.