. 2021 Nov 11;169:229–311. doi: 10.1016/j.resuscitation.2021.10.040

Table 18.

Overview of Studies and Key Outcomes for Methods of Tick Removal

Study	Study design	Certainty of evidence	Population	Outcome	Comparison	Results
Akin Belli et al,⁴⁰⁴ 2016	NR	Low	160 tick removals by health care providers using tweezers or 3 different commercial devices; if tweezers, grabbed close to mouthparts and pulled straight out	Tick removal	Freezing (Tickner) vs pulling with tweezers	0/40 vs 40/40 RR, not estimable
				Intact tick removal	Pulling with a slit-and-traction device (Zeckenkarte) vs pulling with tweezers	3/40 vs 33/40 RR, 0.09 (95% CI, 0.03–0.27)
				Intact tick removal	Pulling with a lasso device (Trix Ticklasso) vs pulling with tweezers	19/40 vs 33/40 RR, 0.58 (95% CI, 0.40–0.83)
Bowles et al,⁴⁰¹1992	RCT	Very low	299 adult ticks removed on 8 stray dogs by researchers using 1 removal device and 3 types of forceps	Ticks with damaged mouthparts	Rotation with opposing jaw device (Tick Solution) vs pulling with economy forceps	2/81 vs 2/73 RR, 0.90 (95% CI, 0.13–6.25)
					Pulling with jeweler’s forceps vs economy forceps	2/72 vs 2/73 RR, 0.90 (95% CI, 0.15–7.00)
					Pulling with angled forceps vs pulling with economy forceps	1/73 vs 2/73 RR, 0.50 (95% CI, 0.05–5.40)
de Boer et al,⁴⁰⁵ 1993	NR	Very low	175 ticks applied on skin of 6 animals were treated chemically; 149 ticks applied on skin of 6 animals were used for pulling vs rotation comparison	Tick removal	Application of gasoline	Removals: 0/72
					Application of nail polish	Removals: 0/46
					Application of methylated spirit	Removals: 0/57
				Tick mouthparts remaining in the skin	Pulling straight out with blunt forceps vs rotation with opposing jaw device (Tick Solution)	59/80 vs 14/69 RR, 3.63 (95% CI, 2.24–5.91)
Duscher et al,⁴⁰² 2012	RCT	Very low	527 ticks removed from animals by 22 veterinarians and 4 lay volunteers; 4 different commercial devices and Adson forceps were tested	Ticks with damaged mouthparts	Rotating mechanical removal vs pulling mechanical removal	37/337 vs 60/190 RR, 0.35 (95% CI, 0.24–0.50)
					Pulling with Adson forceps vs pulling with slit-and-traction device (TickPic)	36/90 vs 24/100 RR, 1.67 (95% CI, 1.08–2.56)
					Rotation with lasso device (Trix Ticklasso) vs pulling with Adson forceps	20/108 vs 36/90 RR, 0.46 (95% CI, 0.29–0.74)
					Rotation with slit-and-rotation device (Tick Twister) vs pulling with Adson forceps	7/108 vs 36/90 RR, 0.16 (95% CI, 0.08–0.35)
					Rotation with opposing jaw device (pen-tweezers) vs pulling with Adson forceps	10/121 vs 36/90 RR, 0.21 (95% CI, 0.11–0.39)
					Rotation with lasso device (Trix Ticklasso) vs pulling with slit-and-traction device (TickPic)	20/108 vs 24/100 RR, 0.77 (95% CI, 0.46–1.31)
					Rotation with slit-and-rotation device (Tick Twister) vs pulling with slit-and-traction device (TickPic)	7/108 vs 24/100 RR, 0.27 (95% CI, 4(0.12–0.60)
					Rotation with opposing jaw device (pen-tweezers) vs pulling with slit-and-traction device (TickPic)	10/121 vs 24/100 RR, 0.34 (95% CI, 0.17–0.69)
					Rotation with lasso device (Trix Ticklasso) vs rotation with slit-and-rotation device (Tick Twister)	20/108 vs 7/108 RR: 2.86 (95% CI, 1.26–6.48)
Duscher et al,⁴⁰² 2012 continued					Rotation with lasso device (Trix Ticklasso) vs rotation with opposing jaw device (pen-tweezers)	20/108 vs 10/121 RR, 2.24 (95% CI, 1.10–4.57)
Duscher et al,⁴⁰² 2012 continued					Rotation with slit-and-rotation device (Tick Twister) vs rotation with opposing jaw device (pen-tweezers)	7/108 vs 10/121 RR, 0.78 (95% CI, 0.31–1.99)
Needham,⁴⁰⁶ 1985	NR	Very low	29 ticks attached to sheep were treated with chemicals or a hot match; 22 ticks attached to sheep were pulled with forceps using various traction techniques	Tick removal	Application of petroleum jelly	Removals: 0/14
					Application of clear fingernail polish	Removals: 0/8
					Application of 70% isopropyl alcohol	Removals: 0/8
					Application of a hot kitchen match	Removals: 0/8
				Ticks with broken mouthparts	Pulling straight up with a quick motion with forceps vs rotating clockwise with forceps	7/7 vs 0/5 RR, 11.25 (95% CI, 0.79–160.81)
					Pulling straight up with a steady pressure with forceps vs rotating clockwise with forceps	5/5 vs 5/5 RR, 1.0 (95% CI, 0.71–1.41)
					Pulling parallel with the skin with forceps vs rotating clockwise with forceps	5/5 vs 5/5 RR, 1.0 (95% CI, 0.71–1.41)
Şahin et al,⁴⁰⁷ 2020	NR	Very low	93 participants who presented to an emergency department for tick removal; ticks were removed either by the participants themselves by hand or by health care providers using a lasso technique with suture material or with tweezers	Ticks with broken mouthparts	Pulling with tweezers or removal by hand	4/22 vs 11/21 RR, 0.35 (95% CI, 0.13–0.92)
Stewart et al,⁴⁰⁸ 1998	NR	Very low	342 ticks were removed from laboratory rabbits by untrained individuals using 4 different commercial removal devices or tweezers	Ticks with damaged mouthparts	Pulling with slit-and-traction device (Ticked Off) vs pulling with medium-tipped tweezers	9/104 vs 20/79 RR, 0.34 (95% CI, 0.16–0.71)
					Pulling with slit-and-traction device (Pro-Tick Remedy) vs pulling with medium-tipped tweezers	13/82 vs 20/79 RR, 0.63 (95% CI, 0.33–1.17)
					Pulling with opposing jaw device (Tick Plier or Tick Nipper) vs pulling with medium-tipped tweezers	10/77 vs 20/79 RR, 0.51 (95% CI, 0.26–1.02)
Zenner et al,⁴⁰³ 2006	RCT	Very low	Veterinarians and pet owners removed 236 ticks (various species) from 178 dogs and 46 cats using 3 commercial tick-removal devices or Adson forceps in random order	Ticks with damaged mouthparts	Rotation with slit-and-rotation device (Tick Twister) vs rotation with opposing jaw device (Buster Tick forceps) or Adson forceps	P<0.01 in favor of slit-and-rotation device; raw data not given

NR indicates nonrandomized study; RCT, randomized controlled trial; and RR, risk ratio.