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Tim Norfolk

@icmtim.bsky.social
727 followers 807 following 243 posts

UK single CCT ICM consultant. Strive to be humbled less often! #Haemodynamics #POCUS #FOAM

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Tim Norfolk @icmtim.bsky.social · 25/02/2026
Thank you @christoslazaridis.bsky.social for writing this 👏 . If I ever found myself on the patient side of such a scenario, I would hope to be cared for by a clinician who shared your views!
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Tim Norfolk @icmtim.bsky.social · 25/02/2026
This piece eloquently articulates my own thoughts on WLST. Current practice leads to avoidable harm, probably for many patients but definitely for their loved ones. We can and have a duty to do better, and should be brave enough to challenge current practice link.springer.com/article/10.1...
link.springer.com
Palliative General Anesthesia at Terminal Extubation: “Go Gentle into that Good Night” - Neurocritical Care
Withdrawal of life-sustaining treatments in the intensive care unit most often culminates into the discontinuation of mechanical ventilation and removal of the endotracheal tube or “terminal extubatio...
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Tim Norfolk @icmtim.bsky.social · 20/02/2026
media.tenor.com
a man in a grey jacket is smiling and the words cool are behind him
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Tim Norfolk @icmtim.bsky.social · 22/01/2026
I was so inspired by so many amazing people, and learnt so much reading others thoughts, but also from composing my own tweetorials. I think it’s a general SoMe fatigue, but it’s all just seems a little pointless now 🤷‍♂️
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Helen Kennedy @helenkennedy.com · 18/01/2026
This is such a cool illustration of how the Mercator map distorts the size of Greenland, which looks as big as the whole continent of Africa on that map but is actually the size of Mexico.
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Tim Norfolk @icmtim.bsky.social · 18/12/2025
These may well be the best years of your life, but I’m just saying 6.30-8.30am aren’t the best hours of those best years 🫠
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Tim Norfolk @icmtim.bsky.social · 17/12/2025
I’m not big on conspiracy theories but this one rings true… #CritcalClosingCriticalSchmosing
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Tim Norfolk @icmtim.bsky.social · 10/12/2025
Congratulations! 🥳
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Tim Norfolk @icmtim.bsky.social · 28/11/2025
media.tenor.com
a cartoon of people walking down a street with the word gio on the bottom left
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NEJM.org @nejm.org · 25/11/2025
In patients with cardiovascular disease and an implantable cardioverter–defibrillator, increasing potassium levels to the high-normal range reduced the risk of arrhythmia events, hospitalizations, and death. Full POTCAST trial results and Research Summary: nej.md/4oQtHTN #MedSky
The New England Journal of Medicine                   
Potassium in Patients at High Risk for Ventricular Arrhythmias 
A Research Summary based on Jøns C et al. | 10.1056/NEJMoa2509542 | Published on August 29, 2025 

Visual representations of the patients in the trial and the treatments they were assigned.    

Read the full Research Summary at NEJM.org.
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Tim Norfolk @icmtim.bsky.social · 16/11/2025
I often wonder when you see patients whose hypoxaemia appears disproportionate to their parenchymal pathology, if impaired pulmonary vasoconstriction due to antihypertensives plays a role. You see some CTs where the consolidated/atelectaric lung looks just so well vascularised 🧐
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Tim Norfolk @icmtim.bsky.social · 14/11/2025
Curious to hear why you’d reach for the washing machine if there’s cerebral oedema? I’d worry it could drag your osmolality down further 🤔
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Tim Norfolk @icmtim.bsky.social · 13/11/2025
No right or wrong answer, but my Monday morning QB response… I think pH is lowest priority. I’d aim for pCO2 4-4.5, bolus 1-2ml/kg 8.4% HCO3 as hyperosmolar therapy, half insulin/dextrose & get a CT to look for features of cerebral oedema
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josh farkas 💊 @pulmcrit.bsky.social · 29/10/2025
The doses of bicarb used were aggressive Interquartile range for total cumulative dose was 500-1000 ml of 4.2% bicarbonate That's equivalent to 5-10 amps (50 ml vials) of 8.4% in the USA You can use a LOT of bicarb if you have to (titrated to effect; also look at Na levels & avoid hyperNa) #4/4
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a woman in a red dress is saying we go hard bravo
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Tim Norfolk @icmtim.bsky.social · 31/10/2025
If you increase your RR from 14 -18 CO2 elimination increases. If production remains constant PaCO2 doesn’t continue to fall indefinitely, a new equilibrium is reached. This is because there’s negative feedback in the loop. Lower blood CO2 levels also mean less CO2 is delivered to alveoli 🔁
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Tim Norfolk @icmtim.bsky.social · 31/10/2025
Only a real rockstar wouldn’t care about losing rockstar levels of engagement 🤟
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Headbang Rock On GIF
ALT: Headbang Rock On GIF
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Tim Norfolk @icmtim.bsky.social · 31/10/2025
It is, but you seem to imply that a sustained increase in EtCO2 isn’t possible. If you increase your RR and MV, CO2 elimination increases, PaCO2 falls and this is sustained. If CO increases, EtCO2 rises, CO2 elimination increases, PaCO2 falls and this is also sustained.
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Tim Norfolk @icmtim.bsky.social · 31/10/2025
EtCO2 is essentially determined by what % of alveoli emptying at end expiration are perfused x PcalillaryCO2. The rise in EtCO2 from better alveolar ventilation will diminish a little as enhanced CO2 clearance leads to a lower PcapCO2 but an equilibrium will be established with sustained ⬆️ EtCO2
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Tim Norfolk @icmtim.bsky.social · 31/10/2025
I’m not sure that’s correct, this assumes there is some fixed baseline EtCO2 value linked to VCO2. In a cardiac arrest EtCO2 falls super low, with ROSC it increases but doesn’t then gradually fall back to the level during the arrest. The rise is sustained, with the sustained CO/alveolar ventilation
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Tim Norfolk @icmtim.bsky.social · 31/10/2025
I really can’t tell if the answer is you, Zoey (I have a 5-yr old daughter so am WELL versed with the characters) or both
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Tim Norfolk @icmtim.bsky.social · 31/10/2025
CO2 production is independent of ventilation, altering alveolar ventilation just affects where the generated CO2 goes. With our simplistic model it can either be blown off, or remain in the body/blood
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Tim Norfolk @icmtim.bsky.social · 31/10/2025
If an ⬆️ in CO, increases EtCO2 then PaCO2 ⬇️ as more CO2 is blown off. PvCO2 will also ⬇️ because of the lower initial PaCO2 & the PvaCO2 gap will fall with the ⬆️ in tissue capillary blood flow. If the exhaled CO2 increases, and VCO2 is constant then CO2 bound to blood will fall in proportion
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Tim Norfolk @icmtim.bsky.social · 31/10/2025
Exactly what you’re imagining
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Tim Norfolk @icmtim.bsky.social · 30/10/2025
Simplify things. Imagine all CO2 produced is either blown off or dissolved in blood then: VCO2 = Exhaled CO2 + CaCO2 CO increases ➡️ alveolar ventilation increases ➡️ EtCO2 increases ➡️ CO2 elimination increases ➡️ PaCO2 decreases 🔁 to equilibrium More CO2 is blown off but less is stored in blood
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Tim Norfolk @icmtim.bsky.social · 30/10/2025
If CO2 production/ventilation is constant and dead space reduces with increasing CO then yes, you will eliminate more CO2 so PaCO2 will also fall, as EtCO2 rises and they’ll get close to meeting in the middle, as a new equilibrium is established. 2/2
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Tim Norfolk @icmtim.bsky.social · 30/10/2025
EtCO2 increases with CO because of a reduction in dead space. Better perfusion to ventilated alveolar units, means more CO2 diffusing to be exhaled. There is a ceiling effect as CO increases and V/Q matching is optimal. EtCO2 will never exceed PaCO2 (although can in funny situations) 1/2
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Tim Norfolk @icmtim.bsky.social · 18/10/2025
That looks excellent!
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Tim Norfolk @icmtim.bsky.social · 12/10/2025
In honor of spooky month, share a 4 word horror story only someone in your profession would understand “Remember that patient you…”
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josh farkas 💊 @pulmcrit.bsky.social · 08/10/2025
normal mentation *doesn't* indicate adequate systemic perfusion especially in cardiogenic shock, people can mentate well despite terrible CO & systemic perfusion poor mentation is sometimes an early sign of *septic* shock, but often a very late indicator of other shock states #EMIMCC
media.tenor.com
Sad Sad Bean GIF
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Tim Norfolk @icmtim.bsky.social · 09/10/2025
One memorable patient for me, transitioned to palliative care for decompensated advanced heart failure. They had a CVP ≈25 and a MAP in the 40s & were mentating just fine for quite some time. There was very little perfusion pressure/CO but the brain clung on til the last possible moment 😢
media.tenor.com
a man in a suit and tie is asking if he can get an amen ?
ALT: a man in a suit and tie is asking if he can get an amen ?
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Tim Norfolk @icmtim.bsky.social · 26/09/2025
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a cartoon man with a mustache is sitting in a chair and the word seconded is written below him
ALT: a cartoon man with a mustache is sitting in a chair and the word seconded is written below him
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Tim Norfolk @icmtim.bsky.social · 06/09/2025
My argument is that experiencing pain is patient focused, even when there is no recall. For example: when people reduce fractures using morphine/midazolam & pts scream in agony, before minutes later asking if anyones pulled their ankle yet. They HAVE suffered, & we should strive to do better.
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Tim Norfolk @icmtim.bsky.social · 06/09/2025
You can do this without lying, which is virtually always the preferable option
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Tim Norfolk @icmtim.bsky.social · 06/09/2025
If our scientific understanding evolves to suggest our current practice is leading to a degree of awareness that causes suffering, even if not recalled by patients, we have a moral imperative to change our practice, and not accept the current standard of care (or by extension, option 1) 2/2
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Tim Norfolk @icmtim.bsky.social · 06/09/2025
So Pete forgive my ignorance around the IFT literature, but have people tried doing it and instead of asking squeeze my hand, saying squeeze my hand if you’re suffering (or something akin to this)? Then we could delineate if the experience at that time was one we should strive to avoid 1/2
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Tim Norfolk @icmtim.bsky.social · 06/09/2025
I don’t think you can genuinely be a number 1 can you, if using any normal/non-IFT definition of awareness. Would you agree to undergo an operation with awareness but the guarantee of being given a perfect amnesiac at the end so you forgot the whole tortuous experience?
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Tim Norfolk @icmtim.bsky.social · 05/09/2025
This is likely why we may be talking at cross purposes then. My gold standard of awareness definitely mandates conscious experience, isolated forearm technique be damned 🤣
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Tim Norfolk @icmtim.bsky.social · 05/09/2025
It was just an example of something you could be aware of. Fundamentally, there is little one could be aware of/experience during an op that wouldn’t be unpleasant, hence the desire for general anaesthesia. Awareness is therefore highly likely to lead to suffering. Amnesia does not obviate this
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Tim Norfolk @icmtim.bsky.social · 05/09/2025
That’s why I caveated my answer by saying if the awareness you refer to was of an unpleasant experience, & I think we can project our lived experiences to this space. I am confident being aware of being intubated would be unpleasant, & don’t feel I need someone’s recollection of this to confirm that
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Tim Norfolk @icmtim.bsky.social · 05/09/2025
I think I disagree, assuming the sensory experience is unpleasant at least. Awareness by definition implies consciously experiencing something. If that something is unpleasant then, to me, that equates to suffering, irrespective of whether the experience is recalled
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Tim Norfolk @icmtim.bsky.social · 05/09/2025
I’m not an anaesthetist so less of a problem for me 😋 But morally I think it is clear that causing suffering regardless of whether or not it recalled should be avoided where possible. The lack of recall does not mean the suffering is not real, therefore it’s an inferior/less acceptable outcome
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Tim Norfolk @icmtim.bsky.social · 05/09/2025
I would hope it is abundantly clear the answer is no. But, if the choice is between awareness with or without recall then I personally would opt for without
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Tim Norfolk @icmtim.bsky.social · 03/09/2025
I try to avoid commenting on anything political on here, but this is TOO DAMN DELICIOUS 🤤
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Tim Norfolk @icmtim.bsky.social · 01/09/2025
This is niche and I’m here for it. Whilst we’re nitpicking Guyton, distinguishing stressed volume from volume seems an unnecessary step. If you have venoconstriction, Pms will rise given the reduction in venous compliance whilst volume remains unchanged. Am I missing something?
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a man wearing a surgical gown and a mask says but why
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Tim Norfolk @icmtim.bsky.social · 30/07/2025
27 ffs, it’s absolutely bonkers isn’t it. Totally agree with your reflections, I liked rotating but think each placement should be a minimum of 6 months, 4 different hospitals in a year is patently insane. But anyway, congrats 🥂, and enjoy setting down some roots!
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Tim Norfolk @icmtim.bsky.social · 29/07/2025
I was lucky enough to visit my god-daughter last week in Toronto, 🇨🇦. She goes to an excellent nursery for $22/d (≈£12) under their CWELCC program. Both parents happily back to work full time. Will doubtless pay for itself (& then some) through higher lifelong maternal earnings/tax revenue.
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Tim Norfolk @icmtim.bsky.social · 29/07/2025
Used as go to push-dose vasopressor in our region of 🇬🇧
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Tim Norfolk @icmtim.bsky.social · 25/07/2025
Correct. Trying to protect children from harmful content and from receiving DMs from predatory adults is so clearly worth the trade off. Additionally most of the people complaining already have a photo of themselves on their profile 🤷‍♂️
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Tim Norfolk @icmtim.bsky.social · 14/07/2025
Those same pts have a RASS of -4/5 though right? I’m sceptical about using EEG in ICU to target sedation when the desired endpoint is clinical (i .e. RASS) not electroencephalogical (real word?). Suspect we’d get more bang for our buck getting the basics right without more gadgetry
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Tim Norfolk @icmtim.bsky.social · 13/07/2025
I just don’t get the anger about this. Features that mean children can’t be sent direct messages from predatory adults is surely a good thing. Why the big upset? I personally applaud any govt/company adopting such measures
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