Diagnosis, Treatment,

and Management of
Systemic Reactions

Bee Stings
(Hymenoptera)
 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.
• Reactions can be varied in intensity from mild
local, to large local, to severe anaphylaxis.
 Statistic
• A large local reaction occurs in 17-56 of those
stung
• Wasps and bees cause 30-120 deaths per year
• Most common in males r/t more frequent exposure
• 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
• 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
Hymenoptera Reactions

• Local Reactions
• Toxic Reactions
• Systemic/Anaphylactic
Reactions
• Delayed Reactions
• Unusual Reactions
 Assessment
Subjectively :
• What activity and location preceded the sting?
• Type of insect activity in the area?
• Was the insect visualized?
• How long ago did the sting occur?
• Did you remove the stinger?
• Is there more than one sting site?
• Do you have pain, trouble breathing, itching,
stomach ache, nausea or vomiting?
• Any history of previous stings, or reaction to
stings?
• Any family history of insect allergies?
• If history suggests anaphylaxis is imminent,
institute treatment immediately
 Assessment cont.

Objective
• Assess site warmth, redness, swelling, drainage,
tenderness
• Is the stinger still present?
• Is there more than one site?
• Compromised distal circulation or sensation?
• Vital signs tachycardia, hypotension, increased
respiratory rate, O2 sat.
• Heart/Lungs wheezing or stridor
• Pallor
• Anxiety
Bee sting with erythema
 Determine Extent of Reaction

• Mild local reaction •Cutaneous responses such as urticaria and

• Redness, itching, pain, swelling angiodema
• •Bronchospasm
Large local reaction
•Large airway obstruction including tongue or
• Will increase in size for 24-48
hours throat swelling and laryngeal edema
• Swelling gt 10cm •Hypotension and shock
• Possible involvement of more than •Differentials
one joint area 5-10 days to resolve •Foreign body
• Systemic reaction Includes a •IV drug use
spectrum of manifestations •Local infection
ranging from mild to life •Cellulitus
threatening •Vasovagal reaction
•Asthma
 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.
• Wash wound and apply ice or cool compresses locally.
• Administer an antihistamine (ex.Benadryl at 5mg/kg/day divided every
eight hours for pruritus x 24-48 hours).
• Oral analgesics as needed for discomfort
• Calamine lotion or one part meat tenderizer mixed
with four parts of water to relieve discomfort.
• Elevate extremity
• Large Local Reactions
• Add Prednisone 40mg PO to above regimen and taper over 4-7 days
 Treatment Plan cont.
• Systemic Allergic Reaction
• Epinephrine 0.01mg/kg of 11000 aqueous solution IM
repeated at 5-15 minute intervals.
• (Administer above the sting site.)
• Antihistamines
• Inhaled bronchodilators such as nebulized Albuterol at 20
minute intervals for wheezing and airway constriction
• H2 antagonists such as Cimetidine or Ranitidine
• Glucocorticoids
• For severe Anaphylaxis, maintain airway and transport to ER
 Follow Up and Instructions
• 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
• Potential for infection at the sting site
• Instruct signs and symptoms of infection, serum
sickness and anaphylaxis to report Instruct in bee
sting avoidance and medic alert bracelet
• Refer for allergy testing with possible RAST and
desensitization-venom immunotherapy (VIT)
• Follow up visit in 24 hours for systemic reaction
to sting
• Patient usually hospitalized 24 hours for
observation in cases of severe anaphylaxis
 References
• 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.
• Tierney, L., McPhee, S., Papadakis, M., (2006), Current
Medical Diagnosis and Treatment, 45th Edition. (pp 791-792).
Lange/McGraw-Hill.
• Burns, C., Dunn, A., Brady, M., Starr, N., Blosser, C., (2004).
Pediatric Primary Care 3rd Edition, (pp 1147-1148). Saunders,
St. Louis, MO.
• http//www.guideline.gov/summary/summary.aspx?
doc_id6888modefulss15 Stinging Insect Hypersensitivity A
Practice Parameter Update. National Guideline
Clearinghouse.
• http//www.emedicine.com/EMERG/topic360.htm Linzer Sr, L.,
(2/9/06) Pediatric Anaphylaxis.
• http//www.emedicine.com/EMERG/topic55.htm Vankawala, H.,
(8/21/06) Bee And Hymenoptra Stings.
 References
• 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.
• Tierney, L., McPhee, S., Papadakis, M., (2006),
Current Medical Diagnosis and Treatment, 45th
Edition. (pp 791-792). Lange/McGraw-Hill.
• Burns, C., Dunn, A., Brady, M., Starr, N.,
Blosser, C., (2004). Pediatric Primary Care 3rd
Edition, (pp 1147-1148). Saunders, St. Louis, MO.
• http//www.guideline.gov/summary/summary.aspx?doc
_id6888modefulss15 Stinging Insect
Hypersensitivity A Practice Parameter Update.
National Guideline Clearinghouse.
• http//www.emedicine.com/EMERG/topic360.htm
Linzer Sr, L., (2/9/06) Pediatric Anaphylaxis.
• http//www.emedicine.com/EMERG/topic55.htm
Vankawala, H., (8/21/06) Bee And Hymenoptra
Stings.