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:
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
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:
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 tic bites. N Eng J Med 1992;327:534-541.
(letters NEJM 1993;328:1418-1420.)
