1. Bee Stings (Hymenoptera) Diagnosis, Treatment, and Management of Systemic Reactions by Deborah Wolff-Baker

2. Pathophysiology of an allergic reaction Immunoglobulin E (IgE) mediated release of histamines, leukotrienes, prostaglandins, and other inflammatory factors, causing local or systemic symptoms. The venom of bees, wasps, and yellow jackets is similar and can cause cross-reactions. The venom of bees, wasps, and yellow jackets is similar and can cause cross-reactions. Reactions can be varied in intensity from mild local, to large local, to severe anaphylaxis. Reactions can be varied in intensity from mild local, to large local, to severe anaphylaxis.

3. Statistics Prevalence and Frequency of Stings in the United States: More than one million stings annually More than one million stings annually A large local reaction occurs in 17-56% of those stung A large local reaction occurs in 17-56% of those stung Wasps and bees cause 30-120 deaths per year Wasps and bees cause 30-120 deaths per year Most common in males r/t more frequent exposure Most common in males r/t more frequent exposure Peak incidence of death from anaphylaxis in those between 35- 45 years of age Peak incidence of death from anaphylaxis in those between 35- 45 years of age Rapid onset is the rule: 50% of deaths occur within 30 minutes of sting and 75% within four hours Rapid onset is the rule: 50% of deaths occur within 30 minutes of sting and 75% within four hours Most commonly a severe reaction follows a previous milder one. The shorter the interval between stings, the more likely a severe reaction will take place Most commonly a severe reaction follows a previous milder one. The shorter the interval between stings, the more likely a severe reaction will take place Fatal reactions can occur as the first generalized reaction, but this is rare Fatal reactions can occur as the first generalized reaction, but this is rare

4. AssessmentSubjective: HPI : What activity and location preceded the sting? What activity and location preceded the sting? Type of insect activity in the area? Type of insect activity in the area? Was the insect visualized? Was the insect visualized? How long ago did the sting occur? How long ago did the sting occur? Did you remove the stinger? Did you remove the stinger? Is there more than one sting site? Is there more than one sting site? Do you have pain, trouble breathing, Do you have pain, trouble breathing, itching, stomach ache, nausea or vomiting? PMH: Any history of previous stings, or reaction to stings? Any history of previous stings, or reaction to stings?FH: Any family history of insect allergies? Any family history of insect allergies? If history suggests anaphylaxis is imminent, institute treatment immediately!

5. Assessment cont. Objective: Assess site: warmth, redness, swelling, drainage, tenderness Assess site: warmth, redness, swelling, drainage, tenderness Is the stinger still present? Is the stinger still present? Is there more than one site? Is there more than one site? Compromised distal circulation or sensation? Compromised distal circulation or sensation? Vital signs: tachycardia, hypotension, increased respiratory rate, O 2 sat. Vital signs: tachycardia, hypotension, increased respiratory rate, O 2 sat. Heart/Lungs: wheezing or stridor Heart/Lungs: wheezing or stridor Pallor Pallor Anxiety Anxiety Bee sting with erythema

6. Determine Extent of Reaction Mild local reaction: Mild local reaction: Redness, itching, pain, swelling Redness, itching, pain, swelling Large local reaction: Large local reaction: Will increase in size for 24-48 hours Will increase in size for 24-48 hours Swelling > 10cm Swelling > 10cm Possible involvement of more than Possible involvement of more than one joint area 5-10 days to resolve 5-10 days to resolve Systemic reaction: Includes a spectrum of manifestations ranging from mild to life threatening: Systemic reaction: Includes a spectrum of manifestations ranging from mild to life threatening: Cutaneous responses such as urticaria and angiodema Cutaneous responses such as urticaria and angiodema Bronchospasm Bronchospasm Large airway obstruction including tongue or throat swelling and laryngeal edema Large airway obstruction including tongue or throat swelling and laryngeal edema Hypotension and shock Hypotension and shock Differentials: Foreign bodyForeign body IV drug useIV drug use Local infectionLocal infection CellulitusCellulitus Vasovagal reactionVasovagal reaction AsthmaAsthma

7. Treatment Plan Mild Local Reactions: Remove any remaining stinger by flicking with the edge of a sharp object. DO NOT squeeze the attached venom sac. Remove any remaining stinger by flicking with the edge of a sharp object. DO NOT squeeze the attached venom sac. Wash wound and apply ice or cool compresses locally. Wash wound and apply ice or cool compresses locally. Administer an antihistamine such as Benadryl at 5mg/kg/day divided every eight hours for pruritus x 24-48 hours. Administer an antihistamine such as Benadryl at 5mg/kg/day divided every eight hours for pruritus x 24-48 hours. Oral analgesics as needed for discomfort Oral analgesics as needed for discomfort Calamine lotion or one part meat tenderizer mixed with four parts of water to relieve discomfort. Calamine lotion or one part meat tenderizer mixed with four parts of water to relieve discomfort. Elevate extremity Elevate extremity Large Local Reactions: Add Prednisone 40mg PO to above regimen Add Prednisone 40mg PO to above regimen and taper over 4-7 days

8. Treatment Plan cont. Systemic Allergic Reaction: Epinephrine 0.01mg/kg of 1:1000 aqueous solution IM repeated at 5-15 minute intervals. Epinephrine 0.01mg/kg of 1:1000 aqueous solution IM repeated at 5-15 minute intervals. (Administer above the sting site.) Antihistamines such as Benadryl or Hydoxyzine Antihistamines such as Benadryl or Hydoxyzine H 2 antagonists such as Cimetidine or Ranitidine H 2 antagonists such as Cimetidine or Ranitidine Inhaled bronchodilators such as nebulized Albuterol at 20 minute intervals for wheezing and airway constriction Inhaled bronchodilators such as nebulized Albuterol at 20 minute intervals for wheezing and airway constriction Glucocorticoids Glucocorticoids And, if severe anaphylaxis, maintain airway and call 911 immediately for ambulance transport to ER !

9. Follow Up and Instructions Potential for rebound or late phase anaphylaxis within 6-12 hours after exposure Potential for rebound or late phase anaphylaxis within 6-12 hours after exposure Serum sickness can occur up to 14 days after sting: S/S are fever, arthralgia, lymphadenopathy, skin eruptions Serum sickness can occur up to 14 days after sting: S/S are fever, arthralgia, lymphadenopathy, skin eruptions Potential for infection at the sting site Potential for infection at the sting site Instruct signs and symptoms of infection, serum sickness and anaphylaxis to report Instruct signs and symptoms of infection, serum sickness and anaphylaxis to report Instruct in bee sting avoidance and medic alert bracelet Instruct in bee sting avoidance and medic alert bracelet Refer for allergy testing with possible RAST and desensitization- venom immunotherapy (VIT) Refer for allergy testing with possible RAST and desensitization- venom immunotherapy (VIT) Rx: Epi-pen and Benadryl and instruct patient in use Rx: Epi-pen and Benadryl and instruct patient in use Follow up visit in 24 hours for systemic reaction to sting Follow up visit in 24 hours for systemic reaction to sting Patient usually hospitalized 24 hours for observation in cases of severe anaphylaxis Patient usually hospitalized 24 hours for observation in cases of severe anaphylaxis

10. References 1. Uphold, C., & Graham, M. (2003). Insect Sting and Brown Recluse Spider Bite. In Clinical Guidelines in Family Practice (pp 950-954). Barmarrae Books, Gainesville, FL. 2. Tierney, L., McPhee, S., Papadakis, M., (2006), Current Medical Diagnosis and Treatment, 45th Edition. (pp 791-792). Lange/McGraw-Hill. 3. Burns, C., Dunn, A., Brady, M., Starr, N., Blosser, C., (2004). Pediatric Primary Care 3rd Edition, (pp 1147-1148). Saunders, St. Louis, MO. 4. http://www.guideline.gov/summary/summary.aspx?doc_id=6888&mode=ful&ss=15 Stinging Insect Hypersensitivity: A Practice Parameter Update. National Guideline Clearinghouse. http://www.guideline.gov/summary/summary.aspx?doc_id=6888&mode=ful&ss=15 5. http://www.emedicine.com/EMERG/topic360.htm Linzer Sr, L., (2/9/06) Pediatric Anaphylaxis. http://www.emedicine.com/EMERG/topic360.htm 6. http://www.emedicine.com/EMERG/topic55.htm Vankawala, H., (8/21/06) Bee And Hymenoptra Stings. http://www.emedicine.com/EMERG/topic55.htm