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Trick of the Trade: Tibial Intraosseous Line Stabilization in an Agitated Patient

Intraosseous needle - image from Dr. Rob CooneyWith the advent of commercial intraosseous (IO) needles for vascular access, administering IV medications for patients in extremis has been made much easier. Securing the IO needle to the patient’s tibia, femur, or humerus, however, is a different story. After successful patient resuscitation, these needles often tenuously secured through creative uses of sterile gauze, trimmed paper cups, bag valve masks, and/or just tape. Stabilization of tibial IO lines can be difficult in a sedated, intubated patient. This can be even more difficult in an agitated, moving patient.

Trick of the Trade

Use a modified knee immobilizer to secure tibial intraosseous lines


Tibial IO Immobilizer How-to

Tibial lines are at risk of trauma and displacement from contact with bed side-rails and the patient’s other leg. This risk is particularly high in the agitated patient and is not sufficiently resolved with traditional ankle restraints.

In order to sufficiently protect a tibial IO, place a knee immobilizer to limit the patient’s movements. Cut a fenestration to allow unobstructed access to the IO. The IO can be further stabilized by packing gauze on either side and covering the leg in a sheet.

Sketch image credit

ALiEM Copyedit by Dr. Michelle Lin

Hi Eric, Seth, and Mark:

A GREAT trick of the trade that I will have to keep in my back pocket of tricks! I made some copyeditor changes to help streamline your message. I removed the introduction about different vascular access techniques since it does not really have to do much with the trick. I also removed mentions of the humeral IO line potentially getting dislodged with arm movement from the discussion. It only begged the question of what trick would help secure such a line. Terrific series of photos which really capture the trick well. Looking forward to feedback from Dr. Mike Paddock. Thanks!

Michelle Lin, MD
ALiEM Editor-in-Chief
Academy Endowed Chair of EM Education
Professor of Clinical Emergency Medicine
University of California, San Francisco

Expert Peer Review by Dr. Mike Paddock

The technique that you describe in this post for protecting a tibial IO line is simple and pragmatic. Knee immobilizers are readily available, are easily modified with bandage (or trauma) shears, and are cost effective. The modified immobilizer serves not only protect the IO site directly, it adds support to the limb for patient transfers (e.g., to the CT table and back). Perhaps most simply, this technique serves as a major visual reminder to all downstream caregivers the location of the IO line so that additional care can be taken to preserve the site.

Your post contains high quality images from start to finish, which the reader can effectively use to achieve the same outcome. For further clarity, additional images involving how the IO dressing was secured with foam tape may help the reader further.

Thank you for allowing me to review this informative and effective approach to stabilizing a tibial IO line.

Mike Paddock, DO, MS
Senior Staff Physician, Emergency Medicine
Regions Hospital, HealthPartners Saint Paul, MN
Assistant Professor, Emergency Medicine University of Minnesota
Seth Trueger, MD MPH

Seth Trueger, MD MPH

Assistant Professor
Department of Emergency Medicine
Northwestern University
Mark Samora

Mark Samora

Staff Nurse
Department of Emergency Medicine
University of Chicago