• A significant number of children present to ED with ticks, typically during the summer months, either for removal or after partial removal at home

• One risk from a tick bite is Lyme disease

• Most cases need only advice rather than treatment with antibiotics

• If the tick is not removed intact do not scrape or dig to remove the residual part. There is no evidence to suggest leaving a small part in situ increases the risk of Lyme disease and the body will expel the part in time

• If Lyme disease symptoms are identified, early antibiotic treatment will usually prevent any long-term complications

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This guideline is designed to support safe nurse led discharge of children presenting to the Emergency department (ED) with ticks in-situ. A significant number of children present to the ED with ticks, typically during summer months, either for removal or after partial removal at home. Most cases need only advice rather than treatment with antibiotics. One risk from a tick bite is Lyme disease. If symptoms are identified early, antibiotic treatment will usually prevent any long-term complications.

• Children who have no systemic symptoms with ticks removed either intact or with part of the head left in-situ

• Observations within normal parameters at triage

• No evidence of cellulitis - there may be a small patch of residual erythema from the tick bite or after removal

• Children whose parents are happy for them to be discharged under a nurse led discharge policy

• Children with a rash or fever at triage

• Children whose parents are unhappy with nurse led discharge

• Source of history (patient / adult)

• Date and time of noticing tick. Location and time of tick bite (if known)

• Site of tick

• Any attempts to remove pre-hospital including what was used and if any part remains in situ

• Any systemic signs of illness, fever, lethargy, rash, flu like symptoms.

• Ensure to also note all other aspects of triage including:

  • Past medical history

  • Medications – regular and since injury

  • Allergies

  • Social situation – who they live with including any social worker (SW)

• Visual inspection of location of tick

• Any associated redness/local erythema/rashes

• Any rashes to other parts of body

• Any other ticks noted to rest of body including in hair – have parents looked at home?

• Complete set of observations

Ensure clear documentation of systemically well child with no fever or rashes and whose parents are happy to be managed under a nurse led discharge policy.

• Ensure child and parent are informed with consent for removal

• Ensure child in a comfortable position

• Use more than one member of staff if required for support/distraction

• Only remove the tick if you are competent and happy to do so

• Using the tick removal tool or small sharp ended tweezers (not blunt eyebrow tweezers and only if no tick remover available) remove the tick from the child’s body.

  • If using tick remover – place device close to the skin, grasp tick with remover forks, twist and pull gently to remove tick

  • If using tweezers - grasp the tick as close to the skin as possible; without squeezing the tick’s body, pull the tick out without twisting (it is difficult to twist tweezers without separating the tick’s head from its body) – there may be considerable resistance

• If the tick is not removed intact, do not scrape or dig to remove the residual part of the tick as there is no evidence to suggest that leaving a small part in situ increases the risk of Lyme disease. Leave in-situ and advise parents the body will deal with it as a foreign body and expel. You can do more damage digging around which can be distressing to the child.

• Explain to parents ongoing care (particularly if head remains in situ) to reassure re: risk of Lyme disease.

The risk from a UK tick bite is very small and you don’t need treatment unless you develop symptoms of illness. The red mark left by the tick bite will fade over a couple of days, so perhaps just make a note on a calendar or diary so, if necessary, you can tell your doctor when the tick bite was and where it was on your body. Lyme disease symptoms appear (on average) about 2 weeks after the tick bite.

• Reassure that prophylactic antibiotic treatment is not necessary (or recommended) but early review is advised if symptoms develop.

• Ensure good verbal advice has been given along with a written advice leaflet.

• Document clearly all interventions, complete notes to GP and discharge.