TICK REMOVAL


OVERVIEW
There are two major families of ticks that bite humans. The Argasidae family (i.e., soft ticks) tend to live around burrows, roots, and nests of birds or reptiles. They attach and feed for minutes to hours and then fall off the prey. The Ixodidae family (i.e., hard ticks) hide in grasses along the sides of animal trails and attach themselves to a passing host. They remain attached until engorged, until they die, or until they are physically removed. In their larval stage, ixodid ticks are known as seed ticks and may infest in great numbers. One anecdotal report demonstrated removal of seed ticks with lindane shampoo.
Hard adult ticks are usually best removed mechanically. A tick attaches to its host with mouthparts equipped with specialized structures designed to hold it embedded in the skin. Most species secrete a cement from the salivary glands that toughens into a hard collar around the mouthparts to help hold it in place. After removal, assess whether the tick is intact by inspecting it for the mouthparts. If they are retained in the skin, it may be necessary to perform a punch biopsy to remove the remnants of the tick.
 
In the past, the application of petroleum jelly, fingernail polish, 70% isopropyl alcohol, or a hot kitchen match was advocated to induce the detachment of adult ticks. However, ticks are extremely hard to suffocate because their respiratory rate is only 15 breaths per hour, and studies have shown that these methods rarely work. Some of these methods may also increase the likelihood that the tick will regurgitate into the site, promoting disease transmission. These techniques are not recommended. There is one anecdotal report of using a 2% viscous lidocaine, which caused the tick to release after about 5 minutes. It is unknown whether this method increases the risk of disease transmission.

Advise patients about the possibility of local or systemic infection, and instruct them to watch for signs of Lyme disease (i.e., erythema marginatum). Excessive bleeding from the removal site is rare and usually easily controlled with standard measures. In cases of a particularly tenacious tick or retained mouthparts, a punch biopsy trephine may be used to remove the local skin and any part of the tick that is attached (see Chapter 10).
Instruct patients on tick infestation prevention methods. When outdoors, protective clothing should be tucked in at the wrists and ankles and sprayed with a tick repellant. Bare skin should have repellant applied every few hours.

INDICATIONS
  • Removal of ticks embedded in the skin

PROCEDURE
The most effective way to remove an embedded tick is a four-step approach.
- First, apply viscous lidocaine to kill the tick and anesthetize the bite site.
- Second, with fine-tipped tweezers or forceps, grasp the tick's head and gently pull upward.
- Alternatively,
  1. Use a small piece of fine suture looped in a half-hitch around the tick, between the skin and the tick's body.
  2. Grasp the tick as close to the skin surface as possible. Avoid puncturing or grasping the body of the tick, as this can lead to rupture of the tick and the release of the rickettsial spirochete.
  3. Third, remove all parts of the tick. Use sharp yet superficial dissection as needed. Residual tick body parts can stimulate a granulomatous reaction and persistent infection.
  4. Fourth, after complete removal of the tick, cleanse and disinfect the skin surface.
  5. Saving the removed tick in a plastic bag can aid in its identification and the diagnosis if illness occurs.
  6. Avoid burning or crushing the tick.
  7. Other remedies to avoid are the use of gasoline, kerosene, petroleum jelly, or fingernail polish. These attempts can increase the propensity to infection by tick regurgitation into the wound site, and often result in incomplete tick removal.

 


(1) After wiping the surrounding area with povidone-iodine, slide a pair of curved hemostats between the skin and the body of the tick.

 


(2) Pull upward and perpendicularly with steady, even pressure
 


(3) A specific tick removal device can be used instead of curved hemostats


 

Tickborne Zoonotic Infections and Specific Treatment

Tickborne Zoonotic Infection Specific Treatment
Rocky Mountain spotted fever Doxycycline: the recommended adult dose is 100 milligrams PO or IV twice a day for 5-10 d, or for 3 d after temperature normalizes. For children weighing <45 kg, the dose is 2.2 milligrams/kg body weight per dose twice daily. Although doxycycline is contraindicated for use in pregnancy, doxycycline may be warranted in life-threatening situations. Although chloramphenicol is still an alternative, it can cause serious toxicity, including myelosuppression, and it is contraindicated in children <2 y of age, pregnancy and breastfeeding, glucose-6-phosphate dehydrogenase deficiency, porphyria, and those with hepatic or renal disease.
Lyme disease Treatment of primary stage and, to some degree, the secondary stage of Lyme disease can be accomplished with several antimicrobial agents: doxycycline, amoxicillin, cefuroxime, ceftriaxone, or erythromycin. The duration of antimicrobial therapy in the primary stage of illness is 14-21 d. The more advanced secondary stage of illness requires longer duration of therapy, up to 28 d. IV antibiotics, ceftriaxone, or penicillin are recommended for the tertiary stage of Lyme disease, with duration of therapy extending from 28-60 d.
A single 200-milligram dose of doxycycline given within 72 h of the deer tick bite is effective in preventing Lyme disease.
Relapsing fever Doxycycline or erythromycin (doxycycline, 100 milligrams PO twice a day for 10 d or erythromycin 500 milligrams four times a day for 10 d).
Chloramphenicol is an alternate.
Colorado tick fever Treatment is supportive.
Tularemia Adults: streptomycin, 1 gram IM twice daily or gentamicin, 5 milligrams/kg IM or IV once daily.
Children: streptomycin, 15 milligrams/kg IM twice daily (should not exceed 2 grams/d).
or
Gentamicin, 2.5 milligrams/kg IM or IV three times daily.
Alternatives: doxycycline, chloramphenicol, or ciprofloxacin.
Babesiosis Atovaquone (750 milligrams PO every 12 h) plus azithromycin (500 milligrams PO on day 1, then 250 milligrams/d) both for 7 to 10 d.
Clindamycin (300 milligrams IV every 6 h) and quinine (650 milligrams orally every 6 h) is an alternative regimen for those severely ill patients.
Ehrlichiosis and anaplasmosis Doxycycline, 100 milligrams PO twice a day for 7 to 14 d. For children weighing <45 kg, the dose is 2.2 milligrams/kg body weight per dose twice daily.