Justin Morgenstern

Justin Morgenstern

@first10em.bsky.social

https://first10em.com/

1.5K followers70 following225 posts

Justin Morgenstern
@first10em.bsky.social

ARISE FLUIDS – Fluids, pressors, neither, both? The management of sepsis has evolved dramatically since I was a trainee, just after Manny Rivers published his seminal sepsis protocol....

first10em.comARISE FLUIDS – Fluids, pressors, neither, both?The management of sepsis has evolved dramatically since I was a trainee, just after Manny Rivers published his seminal sepsis protocol. At this point, I think we mostly know what we are doing. We give antibiotics. We look for a source and get source control. We give some fluids, but not too much. Most importantly, we reassess the patient frequently and make sure they are improving clinically.
Justin Morgenstern
@first10em.bsky.social

Normal saline is not normal and other nonsense that people love to spout (The PRoMPT trial) Personally, I find the normal saline versus balanced fluid debate pretty boring. I don’t really care which you choose....

first10em.comNormal saline is not normal and other nonsense that people love to spout (The PRoMPT trial)Personally, I find the normal saline versus balanced fluid debate pretty boring. I don’t really care which you choose. It seems incredibly unlikely that your choice of crystalloid will have any clinical impact on patients. I use saline, but I don’t really have a strong opinion. I don’t think anyone should have a strong opinion. Ironically, the people with the strongest opinions seem to stray the furthest from the evidence.
Justin Morgenstern
@first10em.bsky.social

3 foot falls and other arbitrary cutoffs we use (Oishi 2026) One reason that clinical judgement regularly beats decision rules is that decision rules (at least as they are currently designed) are forced to use arbitrary cut-offs....

first10em.com3 foot falls and other arbitrary cutoffs we use (Oishi 2026)One reason that clinical judgement regularly beats decision rules is that decision rules (at least as they are currently designed) are forced to use arbitrary cut-offs. Imagine you develop a little bit of pleuritic chest pain during your 50th birthday dinner. Head straight to the hospital while you are still 49 and you are PERC negative. Wait until the next morning because you are having a good time, all of a sudden you are PERC positive.
Justin Morgenstern
@first10em.bsky.social

An RCT of heparin in STEMI The use of heparin in acute coronary syndrome was one of the primary gateways into my…...

first10em.comAn RCT of heparin in STEMIThe use of heparin in acute coronary syndrome was one of the primary gateways into my hatred of guidelines. Medical guidelines contain a lot of recommendations that aren’t exactly evidence based. When you dig into the evidence for heparin in NSTEMI, it becomes pretty clear that it shouldn’t be used, with no long term benefits but clear harms. In fact, …
Justin Morgenstern
@first10em.bsky.social

Some old articles that never rose to the level of a proper critical appraisal, but still might be interesting for some people

first10em.comArticle dump 2026One of the downsides of subscribing to more than 50 journal feeds is the huge number of interesting papers that I flag for later, but never find time to fully appraise. I have been clearing some of these old PDFs out of my computer, but I figured that if the titles caught my eye, you might find them interesting as well.
Justin Morgenstern
@first10em.bsky.social

Should I use antibiotics for strep throat? Do you know why you are actually treating? Short answer: in most places, harms almost certainly outweigh benefits #FOAMed

first10em.comShould I treat Strep throat?It should be the easiest patient of the day. It is just a sore throat. The patient is fine. No signs of epiglottitis or deep space infection. They are clearly going home. But you are working with a curious student, and their questions unearth a tremendous amount of uncertainty. How important is it to identify streptococcus at the cause of pharyngitis, and how accurate are our various tools?
Justin Morgenstern
@first10em.bsky.social

More on invasive PE management The abstract says HI-PEITHO demonstrates benefits - but if you read it yourself, you will probably disagree #FOAMed

first10em.comHI-PEITHO: More negative data on invasive therapy for higher risk PEsOnly a few weeks have passed since I last wrote about negative trials for invasive therapy in pulmonary embolism. You wouldn’t think I would need to spend more time talking about negative research, but the HI-PETHO trial is different, because it is reported as positive, and some people seem to agree. Let’s review the details so you don’t fall into the same trap. 
Justin Morgenstern
@first10em.bsky.social

Paxlvoid doesn't work Are you surprised? The PANORAMIC and CanTreatCOVID trials #FOAMed

first10em.comPaxlovid doesn’t work. Surprise?Despite incredibly underwhelming evidence from the outset, a massive amount of money was spent (or wasted) on Paxlovid during the COVID pandemic. Some of the issues are endemic to medical science. When we allow companies to test their own products with billions of dollars on the line, the results are horrendously biased from the outset. Unfortunately, despite incredibly weak and biased data, Paxlovid (among many other COVID therapeutics) was pushed forward using the incredibly flawed logic that we should lower our scientific standards during a pandemic.
Justin Morgenstern
@first10em.bsky.social

The emergency management of a Tet spell (aka a hypercyanotic episode) #FOAMed

first10em.comThe emergency management of a Tet spell (aka a hypercyanotic episode)A 2 month old boy is brought into the resus room of your community hospital looking completely blue. The mother rather anxiously states that they have been followed at the large pediatric hospital for Tetralogy of Fallot and are awaiting elective repair. Now their child is completely blue, and you were the closest hospital. They were warned about “spells” but can’t remember what to do.

Justin Morgenstern reposted

Casey Parker
@broomedocs.bsky.social

Avalanche Survival in Broome So that is the most ridiculous title that I have ever employed on this blog. Avalanches... Broome.. has Casey finally lost the plot? Well, maybe - but I blame Dr Morgenstern. He sent me an article to review for this month's Journal Club and it forced me down a deep…

broomedocs.comAvalanche Survival in BroomeSo that is the most ridiculous title that I have ever employed on this blog. Avalanches... Broome.. has Casey finally lost the plot? Well, maybe - but I blame Dr Morgenstern. He sent me an article to review for this month's Journal Club and it forced me down a deep rabbit hole into a snowy academia that I never knew existed.
Justin Morgenstern
@first10em.bsky.social

Mirtazipine for methamphetamine? This double-blind RCT demonstrates a reduction in methamphetamine use, which is definitely interesting, but the trial is not without problems #FOAMed

first10em.comMirtazipine for methamphetamine? (McKetin 2026)Addictions are incredibly challenging to treat in the emergency department, although hopefully everyone has accumulated a few wins with suboxone over recent years, and so maintains at least a modicum of optimism. Methamphetamine is much less common around me, but the primary drug of abuse in many areas of the world, and, unlike opioids, methamphetamine addiction does not have approved pharmacotherapeutic options.
Justin Morgenstern
@first10em.bsky.social

2 new RCTs looking at interventional approaches to pulmonary embolism Do you have access to these tools? Should you use them? #FOAMed

first10em.comHigher risk PE management updates (The STRATIFY and STORM-PE trials)I have written fairly extensively about the management of high risk PE. Despite their growing popularity, I have remained quite skeptical of catheter directed therapies. If you are going to give a thrombolytic, my sense is that it is going to be just as effective if given through a peripheral vein, and that fancy catheters add nothing but risk and cost.
Justin Morgenstern
@first10em.bsky.social

Yet again, treating numbers doesn't help This time, we have the first RCT looking at blood pressure targets in spinal cord injury

first10em.comBlood pressure targets in spinal cord injury (Treat patients not numbers)Although guidelines have long suggested higher blood pressure targets in spinal cord injury, that recommendation has never been based on high quality evidence. (Walters 2013; Sanchez 2020) (This is the first ever RCT.) We have a bad habit of treating numbers in medicine, and often making things worse. (Remember the recent paper discussing worse outcomes when we lower blood pressure in ICH, for example…
Justin Morgenstern
@first10em.bsky.social

The first RCT looking at whole blood in trauma is out - and unsurprisingly, there is no benefit #FOAMed

first10em.comNo benefit from whole blood – the SWiFT trialAt this point, most people in the emergency medicine and critical care worlds just assume that balanced (ie, 1:1:1) transfusion is a proven intervention, and the focus has mostly moved on the the potential of whole blood. I am in an almost nonexistent minority when I argue that balanced transfusion is certainly not proven, and may even turn out to be harmful, but that is what the data seems to say.
Justin Morgenstern
@first10em.bsky.social

Another collection of interesting emergency medicine articles #FOAMed

first10em.comResearch Roundup – March 2026Classic medicine: running high cost RCTs that are too small to give real answers Préterre C, Gaultier A, Obadia M, Vignal C, Mourand I, Plat J, Sablot D, Gaudron M, Rodier G, Godeneche G, Urbanczyk C, Marc G, Massardier E, Adam S, Boulanger M, Marcel S, Mechtouff L, Ronzière T, Calvière L, Godard-Ducceschi S, Barbin L, Lebranchu P, Guillon B; THEIA collaborators.
Justin Morgenstern
@first10em.bsky.social

I found it a few hours after my post went live, but if you really want to learn about Dynamic Left Ventricular Outflow Tract Obstruction I might skip my post and listen to the experts talking on EMCrit: emcrit.org/emcrit/dlvoto/

emcrit.orgEMCrit 420 - CV-EMCrit - Nuanced Presentations of Dynamic Left Ventricular Outflow Tract Obstruction (LVOTO): When It’s a “Two-Ventricle” Problem — and So Much MoreHave you diagnosed dLVOTO in the past 3 months? If not, then you missed it!

Justin Morgenstern reposted

Lars Mølgaard Saxhaug
@load-dependent.eurosky.social

One point that isn't mentioned here but too often forgotten when noradrenaline seemingly isn't working: Are you actually using a representative blood pressure? Not so rare that a better (more central or better line) fixes the problem. Look at the whole patient, not just a number! #emimcc #cccsky

Justin Morgenstern @first10em.bsky.social

Norepinephrine isn't work - now what?? A #FOAMed guide to the assessment and management of refractory shock

first10em.comNorepinephrine isn’t work – now what?? (Management of refractory shock)Most resuscitation is pretty straightforward. No matter how sick the patient is, we select from a fairly limited list of interventions. Hypoxia: does the patient need facemask oxygen, highflow, BiPAP, or intubation? Hypotension: fluids, blood, vasopressors? This basic, well used menu serves us incredibly well for the vast majority of resuscitation. It is simple, which helps manage stress in inherently high stress situations.
Justin Morgenstern
@first10em.bsky.social

Norepinephrine isn't work - now what?? A #FOAMed guide to the assessment and management of refractory shock

first10em.comNorepinephrine isn’t work – now what?? (Management of refractory shock)Most resuscitation is pretty straightforward. No matter how sick the patient is, we select from a fairly limited list of interventions. Hypoxia: does the patient need facemask oxygen, highflow, BiPAP, or intubation? Hypotension: fluids, blood, vasopressors? This basic, well used menu serves us incredibly well for the vast majority of resuscitation. It is simple, which helps manage stress in inherently high stress situations.
Justin Morgenstern
@first10em.bsky.social

Don't get BiTEn by bispecific T-cell engagers This novel class of oncology drugs has 2 time sensitive, life threatening complications that emergency clinicians must know #FOAMed

first10em.comDon’t get BiTEn by bispecific T-cell engagersAfter more than a decade on the job, it feels like I should have this emergency medicine thing figured out, but that just doesn’t seem to be how things work. There are constantly new presentations; patients that provoke new questions. However, I find it incredibly disconcerting when something is time sensitive and life threatening - the central area of my expertise - and I have literally never heard of it.
Justin Morgenstern
@first10em.bsky.social

Research Roundup – January 2026 The big paper of the month: ketamine vs etomidate for RSI Casey JD, Seitz KP, Driver BE, et al. Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2025 Dec 9. doi: 10.1056/NEJMoa2511420. Epub ahead of print. PMID: 41369227 On its…

first10em.comResearch Roundup – January 2026The big paper of the month: ketamine vs etomidate for RSI Casey JD, Seitz KP, Driver BE, et al. Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2025 Dec 9. doi: 10.1056/NEJMoa2511420. Epub ahead of print. PMID: 41369227 On its face, this is a fairly simple pragmatic RCT comparing etomidate to ketamine as the induction agent in critically ill adults.
Justin Morgenstern
@first10em.bsky.social

Vernakalant: shockingly fast without the shock? There are many different approaches to stable patients with atrial fibrillation who present to the emergency department. Personally, I have leaned towards electrical cardioversion over chemical cardioversion in patients in whom cardioversion is…

first10em.comVernakalant: shockingly fast without the shock?There are many different approaches to stable patients with atrial fibrillation who present to the emergency department. Personally, I have leaned towards electrical cardioversion over chemical cardioversion in patients in whom cardioversion is appropriate. In the places I work, it is usually faster and easier to get a patient sedated and electrically cardioverted than to wait for drugs to work. However, that is largely because procainamide (the best current best option) is not actually that effective, and is well known for its adverse effects.
Justin Morgenstern
@first10em.bsky.social

Calciphylaxis In the Rapid Review series, I briefly review the key points of a clinical review paper (which often extends to multiple papers because I can’t help myself). The topic this time: Calciphylaxis The papers: Nigwekar SU, Thadhani R, Brandenburg VM. Calciphylaxis. N Engl J Med. 2018 May…

first10em.comCalciphylaxisIn the Rapid Review series, I briefly review the key points of a clinical review paper (which often extends to multiple papers because I can’t help myself). The topic this time: Calciphylaxis The papers: Nigwekar SU, Thadhani R, Brandenburg VM. Calciphylaxis. N Engl J Med. 2018 May 3;378(18):1704-1714. doi: 10.1056/NEJMra1505292. PMID: 29719190 Chewcharat A, Nigwekar SU. Ten tips on how to deal with calciphylaxis patients.
Justin Morgenstern
@first10em.bsky.social

Has etomidate been killing people? Does ketamine cause cardiovascular collapse? Does the RSI trial settle these questions?? #FOAMed

first10em.comKetamine versus Etomidate | The RSI trialSome topics just get people excited. The drugs we use during intubation - well, people are going to have an opinion. Etomidate was popular while I trained, but was actually hard to find in the emergency department. Then came worries of adrenal suppression. Was etomidate just changing biochemical outcomes, or was it actually changing patient outcomes? Was etomidate increasing mortality? That debate drove many into the arms of ketamine, but the data has always been questionable.
Justin Morgenstern
@first10em.bsky.social

Does coffee lead to atrial fibrillation | The DECAF trial You are at a conference. You had 1 glass of wine too many last night, so you had to add an extra coffee to get moving this morning. Then you feel a slight flutter in your chest. Caffeine is a stimulant, right? Could it be causing atrial…

first10em.comDoes coffee lead to atrial fibrillation | The DECAF trialYou are at a conference. You had 1 glass of wine too many last night, so you had to add an extra coffee to get moving this morning. Then you feel a slight flutter in your chest. Caffeine is a stimulant, right? Could it be causing atrial fibrillation? The paper Wong CX, Cheung CC, Montenegro G, Oo HH, Peña IJ, Tang JJ, Tu SJ, Wall G, Dewland TA, Moss JD, Gerstenfeld EP, Tseng ZH, Hsia HH, Lee RJ, Olgin JE, Vedantham V, Scheinman MM, Lee C, Sanders P, Marcus GM.

Justin Morgenstern reposted

NY Times Pitchbot
@nytpitchbot.bsky.social

Under Trump, America is committing war crimes. But under Biden, there were irritating student protests at a college I did not attend. I have never felt more politically homeless.