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Ovid: Atlas of Primary Care Procedures

Editors: Zuber, Thomas J.; Mayeaux, E. J. Title: Atlas of Primary Care Procedures, 1st Edition Copyright ©2004 Lippincott Williams & Wilkins > Table of Contents > General Procedures > 8 – Tick Removal 8 Tick Removal Many people work and play in nonurban areas where they are exposed to tick bites. The tick bite itself usually produces harmless effects, such as mild inflammatory reaction or esthetic distaste. However, several medically important illnesses may develop from microorganisms transmitted by the tick, including Rocky Mountain spotted fever, Q fever, typhus, tick fever, tularemia, babesiosis, relapsing fever, and Lyme disease. Tick-borne diseases can be transmitted by careless handling of infected ticks and through bites. The neurotoxin secreted in the saliva of certain ticks may also result in a progressive ascending paralysis. To limit exposure to potentially pathogenic organisms, expedient and effective tick removal is recommended. 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. P.64
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 Gently paint the surrounding area with povidone-iodine or a similar solution. Slide a pair of curved hemostats between the skin and the body of the tick. Straight forceps, tweezers, or gloved fingers also may be used.

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

Pull upward and perpendicularly, with steady, even pressure. Place the tick in a container of alcohol, and ask the patient to place the container in a freezer in case subsequent identification is warranted. Disinfect the bite site with povidone-iodine scrub or antibacterial soap.

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

PITFALL: Avoid leaving part or all of the arthropod’s head or mouthparts. The further from the head traction is applied, the greater is the chance parts will be broken off. When using hemostats or other grasping devices, grasp the tick as close to the skin surface as possible, and do not twist or jerk the tick. PITFALL: Never squeeze, crush, or puncture the body of the tick, because this may force infectious agents into the wound or onto the examiner. P.66
Alternatively, a specific tick removal device, such as the TICKED OFF device, may be used in place of curved hemostats. While holding TICKED OFF vertical to the skin, place the wide part of the notch on the skin near the tick. Applying slight pressure downward on the skin, slide the remover forward so the small part of the notch is up against the tick. Use a slow, continuous, forward-sliding motion of the remover to detach the tick (a motion similar to scooping hard ice cream from a bucket).

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

CODING INFORMATION There is no specific code for tick removal. Code an appropriate office visit, with a punch biopsy code if a Keys punch is used.

CPT® Code Description 2002 Average 50th Percentile Fee
11100 Skin biopsy $125
CPT® is a trademark of the American Medical Association.

INSTRUMENT AND MATERIALS ORDERING A standard office surgical tray is used for simple surgical procedures (see Appendix A). TICKED OFF may be purchased at Jeffers Pet Supplies (phone: 800-533-3377; http://www.jefferspet.com). BIBLIOGRAPHY Halpern JS. Tick removal. J Emerg Nurs 1988;14:307–309. Jones BE. Human “seed tick” infestation: Amblyomma americanum larvae. Arch Dermatol 1981;117:812–814. Kammholz LP. Variation on tick removal. Pediatrics 1986;78:378–379. Karras DJ. Tick removal. Ann Emerg Med 1998;32:519. Munns R. Punch biopsy of the skin. In: Driscoll CE, Rakel RE, eds. Patient care: procedures for your practice. Oradell, NJ: Medical Economics, 1988. Needham G. Evaluation of five popular methods for tick removal. Pediatrics 1985;75:997–1002. Oteo JA, Casas JM, Martinez de Artola V. Lyme disease in outdoor workers: risk factors, preventive measures, and tick removal methods. Am J Epidemiol 1991;133:754–755. Patterson J, Fitzwater J, Connell J. Localized tick bite reaction. Cutis 1979;24:168–169, 172. Pearn J. Neuromuscular paralysis caused by tick envenomation. J Neurol Sci 1977;34:37–42. Shakman RA. Tick removal. West J Med 1984;140:99.

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