Tim Norfolk
@icmtim.bsky.social
UK single CCT ICM consultant. Strive to be humbled less often!
#Haemodynamics #POCUS #FOAM
#Haemodynamics #POCUS #FOAM
Reposted by Tim Norfolk
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
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
a woman in a red dress is saying we go hard bravo
ALT: a woman in a red dress is saying we go hard bravo
media.tenor.com
October 29, 2025 at 2:59 PM
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
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
In honor of spooky month, share a 4 word horror story only someone in your profession would understand
“Remember that patient you…”
“Remember that patient you…”
In honor of spooky month, share a 4 word horror story only someone in your profession would understand
“They’re for FULL escalation”
“They’re for FULL escalation”
In honor of spooky month, share a 4 word horror story only someone in your profession would understand
“papers in IEEE format”
“papers in IEEE format”
October 12, 2025 at 11:28 AM
In honor of spooky month, share a 4 word horror story only someone in your profession would understand
“Remember that patient you…”
“Remember that patient you…”
Reposted by Tim Norfolk
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
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
Sad Sad Bean GIF
ALT: Sad Sad Bean GIF
media.tenor.com
October 8, 2025 at 9:05 PM
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
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
Reposted by Tim Norfolk
Adjustment of positive end-expiratory pressure based on body mass index during general anaesthesia: a randomised controlled trial
#AnSky
doi.org/10.1111/anae...
#AnSky
doi.org/10.1111/anae...
June 25, 2025 at 12:00 PM
Adjustment of positive end-expiratory pressure based on body mass index during general anaesthesia: a randomised controlled trial
#AnSky
doi.org/10.1111/anae...
#AnSky
doi.org/10.1111/anae...
The fact the furosemide stress test does well at predicting who will need to commence/continue RRT is great (& unsurprising) but it doesn’t help us at the bedside.
The real question is does earlier initiation/re-continuation of RRT help this cohort?
1/
ccforum.biomedcentral.com/articles/10....
The real question is does earlier initiation/re-continuation of RRT help this cohort?
1/
ccforum.biomedcentral.com/articles/10....
Spontaneous diuresis in combination with furosemide stress test (SD-FST) as predictor for successful liberation from kidney replacement therapy: a prospective observational study - Critical Care
Background The optimal time for initiating kidney replacement therapy (KRT) in acute kidney injury (AKI) has been extensively studied in recent years. In contrast, there are currently insufficient dat...
ccforum.biomedcentral.com
June 25, 2025 at 6:36 PM
The fact the furosemide stress test does well at predicting who will need to commence/continue RRT is great (& unsurprising) but it doesn’t help us at the bedside.
The real question is does earlier initiation/re-continuation of RRT help this cohort?
1/
ccforum.biomedcentral.com/articles/10....
The real question is does earlier initiation/re-continuation of RRT help this cohort?
1/
ccforum.biomedcentral.com/articles/10....
Reposted by Tim Norfolk
😱
This is what we were waiting for. A direct comparison between apixaban and rivaroxaban for the treatment of acute VTE. Apixaban reduces bleeding risk in the first 3 months by >50%!
Practice changing investigator-initiated RCT.
#ISTH2025
Practice changing investigator-initiated RCT.
#ISTH2025
June 23, 2025 at 2:00 AM
😱
A normal CT head ≠ a low risk of raised ICP/herniation after LP in meningitis❗️
“80% of pts with ABM who herniate have no CT abnormalities”
🔑 Take-away:
Clinical signs (e.g. GCS <9, seizures, pupil changes) are the best indicators of WHO SHOULD NOT have a LP
journals.sagepub.com/doi/epub/10....
“80% of pts with ABM who herniate have no CT abnormalities”
🔑 Take-away:
Clinical signs (e.g. GCS <9, seizures, pupil changes) are the best indicators of WHO SHOULD NOT have a LP
journals.sagepub.com/doi/epub/10....
Lumbar Puncture and Brain Herniation in Acute Bacterial Meningitis: An Updated Narrative Review
journals.sagepub.com
May 21, 2025 at 6:49 PM
A normal CT head ≠ a low risk of raised ICP/herniation after LP in meningitis❗️
“80% of pts with ABM who herniate have no CT abnormalities”
🔑 Take-away:
Clinical signs (e.g. GCS <9, seizures, pupil changes) are the best indicators of WHO SHOULD NOT have a LP
journals.sagepub.com/doi/epub/10....
“80% of pts with ABM who herniate have no CT abnormalities”
🔑 Take-away:
Clinical signs (e.g. GCS <9, seizures, pupil changes) are the best indicators of WHO SHOULD NOT have a LP
journals.sagepub.com/doi/epub/10....
Reposted by Tim Norfolk
🆕 New RCT in JAMA: Sedation in mechanically ventilated ICU patients—Dexmedetomidine vs Clonidine vs Propofol
📕 Main takeaway: In critically ill patients, neither dexmedetomidine nor clonidine shortened time to successful extubation compared to propofol.
📕 Main takeaway: In critically ill patients, neither dexmedetomidine nor clonidine shortened time to successful extubation compared to propofol.
May 20, 2025 at 1:49 AM
🆕 New RCT in JAMA: Sedation in mechanically ventilated ICU patients—Dexmedetomidine vs Clonidine vs Propofol
📕 Main takeaway: In critically ill patients, neither dexmedetomidine nor clonidine shortened time to successful extubation compared to propofol.
📕 Main takeaway: In critically ill patients, neither dexmedetomidine nor clonidine shortened time to successful extubation compared to propofol.
Procalcitonin- the more we learn, the less we love it 💔
▪️94% of non-septic AKI pts had a Pct >0.5 prior to commencing CRRT
▪️Even using a threshold of >3.2 the specificity was only 38% 🗑️
“Pct in pts with AKI/ESRD should not be measured”
#EMIMCC
ccforum.biomedcentral.com/articles/10....
▪️94% of non-septic AKI pts had a Pct >0.5 prior to commencing CRRT
▪️Even using a threshold of >3.2 the specificity was only 38% 🗑️
“Pct in pts with AKI/ESRD should not be measured”
#EMIMCC
ccforum.biomedcentral.com/articles/10....
Procalcitonin levels in septic and nonseptic subjects with AKI and ESKD prior to and during continuous kidney replacement therapy (CKRT) - Critical Care
Background Procalcitonin is a 14.5 kDa protein used clinically as a marker of sepsis and therapeutic response to antibiotic therapy. However, its utility in critically ill patients with either acute k...
ccforum.biomedcentral.com
May 8, 2025 at 3:26 PM
Procalcitonin- the more we learn, the less we love it 💔
▪️94% of non-septic AKI pts had a Pct >0.5 prior to commencing CRRT
▪️Even using a threshold of >3.2 the specificity was only 38% 🗑️
“Pct in pts with AKI/ESRD should not be measured”
#EMIMCC
ccforum.biomedcentral.com/articles/10....
▪️94% of non-septic AKI pts had a Pct >0.5 prior to commencing CRRT
▪️Even using a threshold of >3.2 the specificity was only 38% 🗑️
“Pct in pts with AKI/ESRD should not be measured”
#EMIMCC
ccforum.biomedcentral.com/articles/10....
Assessing fluid responsiveness in spontaneously breathing MV patients is tough, so this work on SIGH35 by Messina et al. is really 👌
▪️ Apply a 35cm H20 ‘sigh breath’ for 4 secs and measure the change in pulse pressure from baseline to nadir
Simples.
1/
ccforum.biomedcentral.com/articles/10....
▪️ Apply a 35cm H20 ‘sigh breath’ for 4 secs and measure the change in pulse pressure from baseline to nadir
Simples.
1/
ccforum.biomedcentral.com/articles/10....
SIGH35 and end-expiratory occlusion test for assessing fluid responsiveness in critically ill patients undergoing pressure support ventilation - Critical Care
Background Assessing fluid responsiveness is problematic for critically ill patients with spontaneous breathing activity, such as during Pressure Support Ventilation (PSV), since spontaneous breathing...
ccforum.biomedcentral.com
May 7, 2025 at 12:29 PM
Assessing fluid responsiveness in spontaneously breathing MV patients is tough, so this work on SIGH35 by Messina et al. is really 👌
▪️ Apply a 35cm H20 ‘sigh breath’ for 4 secs and measure the change in pulse pressure from baseline to nadir
Simples.
1/
ccforum.biomedcentral.com/articles/10....
▪️ Apply a 35cm H20 ‘sigh breath’ for 4 secs and measure the change in pulse pressure from baseline to nadir
Simples.
1/
ccforum.biomedcentral.com/articles/10....
Sometimes checking an ScvO2 feels pointless, but other times it’s 23%
P.S.
a CO2 gap of 2.3 (17mmHg) must take some beating?
P.S.
a CO2 gap of 2.3 (17mmHg) must take some beating?
April 19, 2025 at 7:26 AM
Sometimes checking an ScvO2 feels pointless, but other times it’s 23%
P.S.
a CO2 gap of 2.3 (17mmHg) must take some beating?
P.S.
a CO2 gap of 2.3 (17mmHg) must take some beating?
Does the over rapid correction of hypernatraemia really cause cerebral oedema in adults❓
Most guidelines suggest a rate of correction < 10mmol/L per day, and whilst there is evidence of risk in children (with tighter, more vulnerable brains) the evidence of risk in adults is scant
1/
Most guidelines suggest a rate of correction < 10mmol/L per day, and whilst there is evidence of risk in children (with tighter, more vulnerable brains) the evidence of risk in adults is scant
1/
two cartoon characters with big brains are standing next to each other in front of a brick wall
ALT: two cartoon characters with big brains are standing next to each other in front of a brick wall
media.tenor.com
April 17, 2025 at 11:12 AM
Does the over rapid correction of hypernatraemia really cause cerebral oedema in adults❓
Most guidelines suggest a rate of correction < 10mmol/L per day, and whilst there is evidence of risk in children (with tighter, more vulnerable brains) the evidence of risk in adults is scant
1/
Most guidelines suggest a rate of correction < 10mmol/L per day, and whilst there is evidence of risk in children (with tighter, more vulnerable brains) the evidence of risk in adults is scant
1/
Basilar artery occlusion accounts for ≈10% of nontraumatic causes of coma
Unconscious without a good explanation? CT head WITH ANGIOGRAPHY is a must❗️
www.sciencedirect.com/science/arti...
#EMIMCC
Unconscious without a good explanation? CT head WITH ANGIOGRAPHY is a must❗️
www.sciencedirect.com/science/arti...
#EMIMCC
Systematic combined noncontrast CT–CT angiography in the management of unexplained nontraumatic coma
Nontraumatic impaired consciousness is a common issue in emergency departments with a serious but widely variable prognosis.The aim of this prospectiv…
www.sciencedirect.com
April 14, 2025 at 2:32 PM
Basilar artery occlusion accounts for ≈10% of nontraumatic causes of coma
Unconscious without a good explanation? CT head WITH ANGIOGRAPHY is a must❗️
www.sciencedirect.com/science/arti...
#EMIMCC
Unconscious without a good explanation? CT head WITH ANGIOGRAPHY is a must❗️
www.sciencedirect.com/science/arti...
#EMIMCC
The finger sweep test is in every article there is on necrotising fasciitis yet in my experience, I’ve never known a surgeon perform it. Indeed they look askance if I’ve suggested it 🫤
Is this a 🇬🇧 thing? Curious to hear other people’s experience…
#EMIMCC
academic.oup.com/bjs/article/...
Is this a 🇬🇧 thing? Curious to hear other people’s experience…
#EMIMCC
academic.oup.com/bjs/article/...
April 9, 2025 at 5:40 PM
The finger sweep test is in every article there is on necrotising fasciitis yet in my experience, I’ve never known a surgeon perform it. Indeed they look askance if I’ve suggested it 🫤
Is this a 🇬🇧 thing? Curious to hear other people’s experience…
#EMIMCC
academic.oup.com/bjs/article/...
Is this a 🇬🇧 thing? Curious to hear other people’s experience…
#EMIMCC
academic.oup.com/bjs/article/...
📢 This bares emphasis 📢
If you’ve started vasopressin for septic shock & the BPs stable/improved but the skin is mottling, you’ve almost certainly made things worse.
VA uncoupling with septic cardiomyopathy is a legit silent 🥷
Pressure ≠ perfusion
If you’ve started vasopressin for septic shock & the BPs stable/improved but the skin is mottling, you’ve almost certainly made things worse.
VA uncoupling with septic cardiomyopathy is a legit silent 🥷
Pressure ≠ perfusion
Think septic cardiomyopathy when pressors are rapidly escalating & not working.
MAP = CO x SVR
↔️ ⬇️ ⬆️
Excess afterload causes the CO to drop. The BP may be relatively stable.
Excess pressors are exacerbating the shock.
Pts may look cool & poorly perfused with ⬆️ cap refill time.
MAP = CO x SVR
↔️ ⬇️ ⬆️
Excess afterload causes the CO to drop. The BP may be relatively stable.
Excess pressors are exacerbating the shock.
Pts may look cool & poorly perfused with ⬆️ cap refill time.
a car is doing a burnout at night with smoke coming out of it 's tires .
ALT: a car is doing a burnout at night with smoke coming out of it 's tires .
media.tenor.com
March 29, 2025 at 6:30 AM
📢 This bares emphasis 📢
If you’ve started vasopressin for septic shock & the BPs stable/improved but the skin is mottling, you’ve almost certainly made things worse.
VA uncoupling with septic cardiomyopathy is a legit silent 🥷
Pressure ≠ perfusion
If you’ve started vasopressin for septic shock & the BPs stable/improved but the skin is mottling, you’ve almost certainly made things worse.
VA uncoupling with septic cardiomyopathy is a legit silent 🥷
Pressure ≠ perfusion
Time to dump my shares in Sedaconda!
Inhaled Sevoflurane led to increased 90d mortality compared to propofol (52.9% v 44.3%) in pts with ARDS
(Also median duration of NMB use of 5 days in both groups seems wild 🫤)
jamanetwork.com/journals/jam...
#MedSky #EMIMCC
Inhaled Sevoflurane led to increased 90d mortality compared to propofol (52.9% v 44.3%) in pts with ARDS
(Also median duration of NMB use of 5 days in both groups seems wild 🫤)
jamanetwork.com/journals/jam...
#MedSky #EMIMCC
Inhaled Sedation in Acute Respiratory Distress Syndrome
This clinical trial compares the efficacy of inhaled sevoflurane vs intravenous propofol for sedation in patients with acute respiratory distress syndrome.
jamanetwork.com
March 27, 2025 at 7:06 PM
Time to dump my shares in Sedaconda!
Inhaled Sevoflurane led to increased 90d mortality compared to propofol (52.9% v 44.3%) in pts with ARDS
(Also median duration of NMB use of 5 days in both groups seems wild 🫤)
jamanetwork.com/journals/jam...
#MedSky #EMIMCC
Inhaled Sevoflurane led to increased 90d mortality compared to propofol (52.9% v 44.3%) in pts with ARDS
(Also median duration of NMB use of 5 days in both groups seems wild 🫤)
jamanetwork.com/journals/jam...
#MedSky #EMIMCC
A great opportunity to recite this 💎:
1L of 0.9% Saline contains as much salt as 23 packets of Walkers Cheese & Onion crisps
That initial 3L resus = 69 bags worth‼️
It’s no wonder people get a bit puffy as their poor kidneys battle to pee out all that 🧂😵💫🧂
1L of 0.9% Saline contains as much salt as 23 packets of Walkers Cheese & Onion crisps
That initial 3L resus = 69 bags worth‼️
It’s no wonder people get a bit puffy as their poor kidneys battle to pee out all that 🧂😵💫🧂
March 19, 2025 at 8:30 PM
A great opportunity to recite this 💎:
1L of 0.9% Saline contains as much salt as 23 packets of Walkers Cheese & Onion crisps
That initial 3L resus = 69 bags worth‼️
It’s no wonder people get a bit puffy as their poor kidneys battle to pee out all that 🧂😵💫🧂
1L of 0.9% Saline contains as much salt as 23 packets of Walkers Cheese & Onion crisps
That initial 3L resus = 69 bags worth‼️
It’s no wonder people get a bit puffy as their poor kidneys battle to pee out all that 🧂😵💫🧂
Reposted by Tim Norfolk
Adolescence on Netflix is fucking astonishing, urgent, vital and it hurts your heart. Incredible cast, direction and writing. You must watch it. You just must.
March 13, 2025 at 7:06 PM
Adolescence on Netflix is fucking astonishing, urgent, vital and it hurts your heart. Incredible cast, direction and writing. You must watch it. You just must.
Having discontinued Melatonin on numerous occasions (murmuring Pro-MEDIC to any poor soul who’ll listen) the rec FOR melatonin is quite triggering…
Now to decide if I’ve got the humility to question my assertions & revisit the issue or just go full ‘Marik’ mode
💡 Ivermectin for delirium ⁉️
Now to decide if I’ve got the humility to question my assertions & revisit the issue or just go full ‘Marik’ mode
💡 Ivermectin for delirium ⁉️
brief skytorial on the latest SCCM PADIS guideline update.
this is a nice, useful, & concise statement that will change my practice.
there are basically two take-home messages...
(🧵 #1/3)
journals.lww.com/ccmjournal/a... #EMIMCC
this is a nice, useful, & concise statement that will change my practice.
there are basically two take-home messages...
(🧵 #1/3)
journals.lww.com/ccmjournal/a... #EMIMCC
March 9, 2025 at 6:14 PM
Having discontinued Melatonin on numerous occasions (murmuring Pro-MEDIC to any poor soul who’ll listen) the rec FOR melatonin is quite triggering…
Now to decide if I’ve got the humility to question my assertions & revisit the issue or just go full ‘Marik’ mode
💡 Ivermectin for delirium ⁉️
Now to decide if I’ve got the humility to question my assertions & revisit the issue or just go full ‘Marik’ mode
💡 Ivermectin for delirium ⁉️
Reposted by Tim Norfolk
brief skytorial on the latest SCCM PADIS guideline update.
this is a nice, useful, & concise statement that will change my practice.
there are basically two take-home messages...
(🧵 #1/3)
journals.lww.com/ccmjournal/a... #EMIMCC
this is a nice, useful, & concise statement that will change my practice.
there are basically two take-home messages...
(🧵 #1/3)
journals.lww.com/ccmjournal/a... #EMIMCC
March 7, 2025 at 7:20 PM
brief skytorial on the latest SCCM PADIS guideline update.
this is a nice, useful, & concise statement that will change my practice.
there are basically two take-home messages...
(🧵 #1/3)
journals.lww.com/ccmjournal/a... #EMIMCC
this is a nice, useful, & concise statement that will change my practice.
there are basically two take-home messages...
(🧵 #1/3)
journals.lww.com/ccmjournal/a... #EMIMCC
📝
▫️Clonidine should be carefully considered as there is a paucity of evidence around its use
▫️ Consider Haloperidol (first line) for psychomotor symptoms
My colleagues will be gutted, but I’m all for the #VitaminH ❤️
▫️Clonidine should be carefully considered as there is a paucity of evidence around its use
▫️ Consider Haloperidol (first line) for psychomotor symptoms
My colleagues will be gutted, but I’m all for the #VitaminH ❤️
Delirium in critically ill patients is a serious but often underdiagnosed condition.
Our new guidelines offer expert recommendations for early detection, prevention, and management in the ICU.
Let's improve outcomes together!
Read below now👇
bit.ly/deliriumicsguidance
Our new guidelines offer expert recommendations for early detection, prevention, and management in the ICU.
Let's improve outcomes together!
Read below now👇
bit.ly/deliriumicsguidance
February 25, 2025 at 8:25 AM
📝
▫️Clonidine should be carefully considered as there is a paucity of evidence around its use
▫️ Consider Haloperidol (first line) for psychomotor symptoms
My colleagues will be gutted, but I’m all for the #VitaminH ❤️
▫️Clonidine should be carefully considered as there is a paucity of evidence around its use
▫️ Consider Haloperidol (first line) for psychomotor symptoms
My colleagues will be gutted, but I’m all for the #VitaminH ❤️
An excellent (albeit a little scary) retrospective study of arterial injury after CVC insertion.
A National Audit Project looking at CVCs is a fantastic idea, & would hopefully help us answer additional questions (i.e. optimal insertion site, routine line changes, fixation device)
#EMIMCC
A National Audit Project looking at CVCs is a fantastic idea, & would hopefully help us answer additional questions (i.e. optimal insertion site, routine line changes, fixation device)
#EMIMCC
Arterial trauma is a rare, but potentially life-threatening complication of central venous catheter insertion.
In this interrogation of two national databases of incident reports, outcomes included:
• stroke (10%)
• death (4%)
#AnSky #MedSky
https://doi.org/10.1111/anae.16570
In this interrogation of two national databases of incident reports, outcomes included:
• stroke (10%)
• death (4%)
#AnSky #MedSky
https://doi.org/10.1111/anae.16570
February 23, 2025 at 7:00 PM
An excellent (albeit a little scary) retrospective study of arterial injury after CVC insertion.
A National Audit Project looking at CVCs is a fantastic idea, & would hopefully help us answer additional questions (i.e. optimal insertion site, routine line changes, fixation device)
#EMIMCC
A National Audit Project looking at CVCs is a fantastic idea, & would hopefully help us answer additional questions (i.e. optimal insertion site, routine line changes, fixation device)
#EMIMCC
Thoughts and prayers to the poor centurion who got put on VA-ECMO 🥺
#Zentensivsim
link.springer.com/article/10.1...
#Zentensivsim
link.springer.com/article/10.1...
Utilization and outcomes of life-supporting interventions in older ICU patients in Japan: a nationwide registry study - Intensive Care Medicine
Purpose The purpose of this study is to describe the implementation of life-supporting interventions and the short-term outcomes of older patients in ICUs in Japan. Methods All adult patients admitted...
link.springer.com
February 22, 2025 at 6:44 PM
Thoughts and prayers to the poor centurion who got put on VA-ECMO 🥺
#Zentensivsim
link.springer.com/article/10.1...
#Zentensivsim
link.springer.com/article/10.1...
Some very challenging interactions with a new surgical colleague this morning
#ILookLikeASurgeon
👩⚕️ 🥰 🦄
#ILookLikeASurgeon
👩⚕️ 🥰 🦄
February 20, 2025 at 5:36 PM
Some very challenging interactions with a new surgical colleague this morning
#ILookLikeASurgeon
👩⚕️ 🥰 🦄
#ILookLikeASurgeon
👩⚕️ 🥰 🦄