Finding a tick on oneself or a family member can be anxiety provoking. Ticks are known to carry many diseases, and the list is growing. Additionally, the range of ticks is expanding, likely caused by climate changes. Tick removal requires awareness of several factors, in addition to knowing how to remove the tick. A clinician should consider the following questions: What type of tick is it? What is the geography of the attached tick? What else needs to be done for a person who has had a tick removed? This activity summarizes information about tick identification and the tick removal technique.
Review the range (geographic distribution) of the Ixodes species of ticks, the carriers of Lyme disease.
Summarize options and actions for tick removal.
Identify concerns and reasonable actions when a tick is discovered on a patient.
Outline how members of an interprofessional interprofessional team can evaluate and remove a tick and then provide the best possible follow up care.
Finding a tick on oneself or a family member can be anxiety provoking. Ticks are known to carry many diseases, and the list is growing. Additionally, the range of ticks is expanding, likely caused by climate changes.
Tick removal requires awareness of several factors, in addition to knowing how to remove the tick. A clinician should consider the following questions:
What type of tick is it? (See references, including pictures, from the Centers for Disease Control and Prevention (CDC))
What is the geography of the attached tick? (See distribution maps via links to CDC)
What else needs to be done for a person who has had a tick removed? (See the Infectious Disease Society of position paper attached)
The following sections summarize information about tick identification and tick removal technique.
Tick removal is indicated when a patient presents with an attached tick on their body.
Indication for additional treatment is based partially on geography. A basic understanding of tick distribution will help an individual know when to be concerned. After being in an area of possible tick infestation, individuals should perform a full-body inspection. Pay particular attention to children and take meticulous care of crevices and hair. If a tick is found attached, identify it first. It may be best to do this before removal because the tick might not be intact after removal. Estimate the time of attachment. If the tick has taken blood, a time-dependent process, prophylaxis against tick-borne disease may be indicated in areas of high prevalence.
The American dog tick (Dermacentor variabilis) is widely distributed east of the Rocky Mountains and in limited areas along the Pacific Coast. This tick transmits tularemia, and Rocky Mountain spotted fever. The highest risk of tick bites occurs during spring and summer. Dog ticks are sometimes called wood ticks. Adult females are most likely to bite humans.
The blacklegged tick (Ixodes scapularis) is widely distributed in the northeastern and upper midwestern United States. They transmit Lyme disease, anaplasmosis, babesiosis, and Powassan disease. The greatest risk for bites exists in the spring, summer, and fall. However, adults may be out searching for a host any time when winter temperatures are above freezing. Nymphs and adult females are most likely to bite humans.
The brown dog tick (Rhipicephalus sanguineus) is found worldwide. Brown dog ticks transmit Rocky Mountain spotted fever (in the southwestern United States and along the U.S./Mexico border). Dogs are the primary host for the brown dog tick in each of its life stages, but the tick may also bite humans or other mammals.
The Gulf Coast tick (Amblyomma maculatum) is found in coastal areas of the United States, specifically the Atlantic coast and the Gulf of Mexico. It transmits Rickettsia parkeri rickettsiosis, a form of spotted fever. Larvae and nymphs feed on birds and small rodents, while adult ticks feed on deer and other wildlife. Adult ticks have been associated with the transmission of R. parkeri in humans.
The lone star tick (Amblyomma americanum) is widely distributed in the southeastern and eastern United States. It transmits Ehrlichia chaffeensis and Ehrlichia ewingii (which cause human ehrlichiosis), tularemia, and STARI (southern tick-associated rash illness.) It is a very aggressive tick that bites humans. The adult female is distinguished by a white dot or “lone star” on her back. Lone star tick saliva can be irritating. Redness and discomfort at the bite site do not necessarily indicate an infection. The nymph and adult females most frequently bite humans and transmit disease.
Rocky Mountain wood tick (Dermacentor andersoni) is found in the Rocky Mountain states and southwestern Canada from elevations of 4000 ft to 10,500 ft. This tick transmits Rocky Mountain spotted fever, Colorado tick fever, and tularemia. These adult ticks feed primarily on large mammals. Larvae and nymphs feed on small rodents. Adult ticks are primarily associated with pathogen transmission to humans.
Western blacklegged tick (Ixodes pacificus) is found along the Pacific coast of the United States, particularly Northern California. It transmits anaplasmosis and Lyme disease. Nymphs often feed on lizards, as well as other small animals. As a result, rates of infection are usually low (approximately 1%) in adults. Nymphs and adult females are most likely to bite humans.
There are no contraindications to tick removal.
Sterile tweezers or hemostats that are in good working order, with tips that mate/align
2"X2" gauze squares
Topical antibiotic ointment
This procedure can be done by some patients at home. If the patient presents to the clinic, any primary clinician can perform a tick removal. The clinician is often assisted by a nurse or technician.
The patient should be positioned in a comfortable position. The site of the attached tick may be cleaned with an alcohol prep.
Grasp the tick at the head, right where it has attached to the skin. Be sure to grasp the head, not the body, as pulling off the body will leave the head attached. If the head is not removed, this becomes a location for infection to set in, and its removal becomes a much more difficult process.
Pull suddenly and directly away from the skin. Expect a tiny patch of the skin to come away with the tick. Once the tick has been identified, dispose of it securely.
Post removal care includes routine cleaning of the skin and the application of a topical antibiotic. Bacitracin is recommended. Apply a wound dressing over the area.
The main complications of tick removal include retained head, patient discomfort, and risk of infection. If there is a retained head, the removal may require local anesthesia and more invasive instrumentation. This can increase patient discomfort and infection risk.
Lyme Disease, Post Tick Removal Prophylaxis
Post tick removal, prophylaxis against Lyme disease, raises concerns. In general, if the tick is in an area with a high likelihood of Borrelia burgdorferi, but the tick has not eaten a blood meal, infection is unlikely. Prophylaxis is recommended when all of the following circumstances exist: (1) the attached tick can be reliably identified as an adult or nymphal I. scapularis tick that is estimated to have been attached more than 36 hours on the basis of the degree of engorgement of the tick with blood or on certainty about the time of exposure to the tick, (2) prophylaxis can be started within 72 hours of the time that the tick was removed, (3) ecologic information indicates that the local rate of infection of these ticks with B. burgdorferi is greater than 20%, and (4) doxycycline is not contraindicated. If prophylaxis is advisable, a single dose of doxycycline may be offered to adult patients (200 mg dose) and to children less than 8 years of age (4 mg/kg, up to a maximum dose of 200 mg). The time limit of 72 hours is suggested because of the absence of data on the efficacy of chemoprophylaxis for tick bites following tick removal after longer time intervals. Infection of more than 20% of ticks with B. burgdorferi occurs in parts of New England, in parts of the mid-Atlantic States, and in parts of Minnesota and Wisconsin, but not in most other locations in the United States. Whether the use of antibiotic prophylaxis after a tick bite will reduce the incidence of HGA or babesiosis is unknown.
It is not recommended to use amoxicillin instead of doxycycline in persons for whom doxycycline is contraindicated because of the absence of data on an effective short-course regimen for prophylaxis, the likely need for a multi-day regimen (and its associated adverse effects), the efficacy of antibiotic treatment of Lyme disease if infection were to develop, and the low risk that a person with a tick bite will develop a serious complication of Lyme disease. Patients should be educated to seek care if they develop signs or symptoms of Lyme disease after tick removal whether or not they are given prophylaxis.
Prevention of tick bites to avoid complications include:
Avoiding tick-infested areas
Using diethyltoluamide (DEET) on the skin according to label directions
Applying permethrin to clothing
Wearing clothing in a downward cascade. Pants go over the tops of boots to ensure that ticks that fall off do not fall in your boots. For overlapping clothes, ensure the bands have no gaps.
Enhancing Healthcare Team Outcomes
During spring and summer, patients may present to the primary care provider, nurse practitioner, physician assistant, or the emergency department clinician with ticks on their body. These professionals should know how to manage ticks. After the tick is identified, it should be removed. The patient must be followed up to ensure that he or she has not developed any signs of infection. In some regions, prophylactic antibiotics may be considered due to the high incidence of systemic infections.
The interprofessional team should consider consulting with an infectious disease expert to determine what type of treatment is needed after tick removal. The nurse must educate the patient on possible complications such as local or systemic infections. If the patient and family are unclear, the nurse should request further consultation with the clinician. The best results are achieved when the interprofessional team thoroughly educates the patient on the risks of tick-related infection, and measures are taken to control the risk. The pharmacist should ensure medication compliance if a systemic infection is being treated. If non-compliance is a concern, the clinical team should be contacted.
(Click Image to Enlarge)
Western blacklegged tick
Contributed by the Centers for Disease Control and Prevention (CDC)
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