11.09 Tick Removal
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agk's Library of Common Simple Emergencies

Presentation
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The patient arrives with a tick attached to the 
skin, often the scalp, often frightened or 
disgusted and concerned about developing Lyme 
Disease, Rocky Mountain Spotted Fever or "tick 
fever."

What to do:
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- Promptly remove the tick. Grasp the tick with a 
    pair of forceps and slowly pull up until the 
    tick mouth parts separate from the skin.
- If the mouth parts remain embedded, anesthetize 
    the area with an infiltration of 1% Xylocaine 
    and use a #10 scalpel blade to scrape 
    (dermabrade) these fragments away.
- Instruct the patient or family to record the 
    patient's temperature daily for the next two 
    weeks and to notify a physician or return to 
    the ED at the first sign of a temperature 
    above the baseline.
- If this was a 5mm Ixodes or deer tick, which 
    was attached for more than a few hours, 
    consider prescribing antibiotics to prevent 
    Lyme disease (doxycycline 100mg bid x 10d, 
    amoxicillin 500mg tid x 10d). Instruct the 
    family to watch for a pink patch at the site, 
    which could be the beginning of erythema 
    chronica migrans.
- If this was a 1 cm Dermacentor or Amblyomma 
    tick, reassure the patient and family that 
    the likelihood of developing Rocky Mountain 
    spotted fever is very small (l%) and that if 
    it should occur, prompt treatment will be 
    quite effective upon development of fever. It 
    is counterproductive to give prophylactic 
    antibiotics in an attempt to prevent RMSF.

What not to do:
---------------

- Do not use heat, occlusion, or caustics to 
    remove a tick. A multitude of techniques have 
    been promoted, but they may only increase the 
    chance of infection.
- Do not contaminate your fingers with 
    potentially infected tick products.
- Do not mutilate the skin attempting to remove 
    the tick's "head." Usually what you see left 
    behind is cememtum secreted by the tick, 
    easily scraped off.

Discussion
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Ixodes dammini, the tiny deer tick of New 
England, carries babesiosis and Lyme disease. 
Dermacentor variabilis, the dog tick, is the 
major vector of Rocky Mountain spotted fever, 
which is also carried by D. andersoni, the 
western wood tick, and Amblyomma americanum, the 
lone star tick. A. americanum has particularly 
long mouth parts, and its larvae are also capable 
of infesting human hosts. Other diseases carried 
by ticks include tick paralysis (usually cured by 
removing the tick), Colorado tick fever, 
relapsing fever, Q fever, Erlichosis and 
tularemia.

References:
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- Needham GR: Evaluation of five popular methods 
    for tick removal. *Pediatrics* 1985;
    75:997-1002.
- Magid D, Schwartz B, Craft J, Schwartz JS: 
    Prevention of Lyme disease after tick bites. 
    *N Eng J Med* 1992;327:534-541. (letters 
    *NEJM* 1993;328:1418-1420.)

Illustration
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img/cse1109.gif

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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