Bee Stings ( H y m e n o p t e r a )

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!

5. 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

6. Determine Extent of Reaction • Differentials: • Foreign body • IV drug use • Local infection • Cellulitus • Vasovagal reaction • Asthma • Mild local reaction: • Redness, itching, pain, swelling • Large local reaction: • Will increase in size for 24-48 hours • Swelling > 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

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. • 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

8. Treatment Plan cont. Systemic Allergic Reaction: • 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 • 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 !

9. 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

10. References • Uphold, C., & Graham, M. (2003). Insect Sting and Brown Recluse Spider Bite. InClinical 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_id=6888&mode=ful&ss=15 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.