Bee Stings (Hymenoptera)

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.
• 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
• 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

4
Assessment

• Subjective
• HPI
• 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?
• PMH
• Any history of previous stings, or reaction to
  stings?
• FH
• Any family history of insect allergies?

• If history suggests anaphylaxis is imminent,
  institute treatment immediately!

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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
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Determine Extent of Reaction

• Mild local reaction
• Redness, itching, pain, swelling
• Large local reaction
• Will increase in size for 24-48 hours
• Swelling gt 10cm
• Possible involvement of more than
• one joint area
• 5-10 days to resolve
• Systemic reaction Includes a spectrum of
  manifestations ranging from mild to life
  threatening
• Cutaneous responses such as urticaria and
  angiodema
• Bronchospasm
• Large airway obstruction including tongue or
  throat swelling and laryngeal edema
• Hypotension and shock

• Differentials
• Foreign body
• IV drug use
• Local infection
• Cellulitus
• Vasovagal reaction
• Asthma

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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 such as 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

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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 such as Benadryl or Hydoxyzine
• H2 antagonists such as Cimetidine or Ranitidine
• Inhaled bronchodilators such as nebulized
  Albuterol at 20 minute intervals for wheezing and
  airway constriction
• Glucocorticoids
• And, if severe anaphylaxis,
• maintain airway and
• call 911 immediately for
• ambulance transport to ER !

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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)
• Rx Epi-pen and Benadryl and instruct patient in
  use
• Follow up visit in 24 hours for systemic reaction
  to sting
• Patient usually hospitalized 24 hours for
  observation in cases of severe anaphylaxis

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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
   _id6888modefulss15 Stinging Insect
   Hypersensitivity A Practice Parameter Update.
   National Guideline Clearinghouse.
5. http//www.emedicine.com/EMERG/topic360.htm
   Linzer Sr, L., (2/9/06) Pediatric Anaphylaxis.
6. http//www.emedicine.com/EMERG/topic55.htm
   Vankawala, H., (8/21/06) Bee And Hymenoptra
   Stings.