Bee Stings Bee Stings ((HHyymmeennoopptteerraa))

Diagnosis, Treatment, and Diagnosis, Treatment, and Management of Management of

Systemic ReactionsSystemic Reactions

bybyDeborah Wolff-BakerDeborah Wolff-Baker

Pathophysiology of an Pathophysiology of an allergic reactionallergic reaction

Immunoglobulin E (IgE) mediated release of Immunoglobulin E (IgE) mediated release of histamines, leukotrienes, prostaglandins, histamines, leukotrienes, prostaglandins, and other inflammatory factors, causing and other inflammatory factors, causing local or systemic symptoms.local or systemic symptoms.

The venom of bees, wasps, and yellow jackets The venom of bees, wasps, and yellow jackets is similar and can cause cross-reactions.is similar and can cause cross-reactions.

Reactions can be varied in intensity from mild Reactions can be varied in intensity from mild local, to large local, to severe anaphylaxis.local, to large local, to severe anaphylaxis.

StatisticsStatisticsPrevalence and Frequency of Stings in the United Prevalence and Frequency of Stings in the United

States:States:

More than one million stings annually More than one million stings annually A large local reaction occurs in 17-56% of those stungA large local reaction occurs in 17-56% of those stung Wasps and bees cause 30-120 deaths per yearWasps and bees cause 30-120 deaths per year Most common in males r/t more frequent exposureMost common in males r/t more frequent exposure Peak incidence of death from anaphylaxis in those Peak incidence of death from anaphylaxis in those

between 35-45 years of agebetween 35-45 years of age Rapid onset is the rule: 50% of deaths occur within 30 Rapid onset is the rule: 50% of deaths occur within 30

minutes of sting and 75% within four hoursminutes of sting and 75% within four hours Most commonly a severe reaction follows a previous Most commonly a severe reaction follows a previous

milder one. The shorter the interval between stings, milder one. The shorter the interval between stings, the more likely a severe reaction will take placethe more likely a severe reaction will take place

Fatal reactions can occur as the first generalized Fatal reactions can occur as the first generalized reaction, but this is rarereaction, but this is rare

AssessmentAssessment Subjective:Subjective:

HPIHPI:: 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?itching, stomach ache, nausea or vomiting?PMH:PMH: Any history of previous stings, or reaction to stings?Any history of previous stings, or reaction to stings?FH:FH: Any family history of insect allergies?Any family history of insect allergies?

If history If history suggests suggests

anaphylaxis is anaphylaxis is imminent, imminent, institute institute

treatment treatment immediately!immediately!

Assessment cont.Assessment cont.Objective:Objective: Assess site: warmth, redness, swelling, drainage, Assess site: warmth, redness, swelling, drainage,

tendernesstenderness 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 Vital signs: tachycardia, hypotension, increased

respiratory rate, Orespiratory rate, O22 sat. sat. Heart/Lungs: wheezing or stridor Heart/Lungs: wheezing or stridor PallorPallor AnxietyAnxiety

Bee sting with erythema

Determine Extent of ReactionDetermine Extent of Reaction

Mild local reaction:Mild local reaction: Redness, itching, pain, swellingRedness, itching, pain, swelling

Large local reaction:Large local reaction: Will increase in size for 24-48 hoursWill increase in size for 24-48 hours Swelling > 10cm Swelling > 10cm Possible involvement of more than Possible involvement of more than

one joint areaone joint area 5-10 days to resolve5-10 days to resolve

Systemic reaction: Includes a spectrum of Systemic reaction: Includes a spectrum of manifestations ranging from mild to life threatening:manifestations ranging from mild to life threatening: Cutaneous responses such as urticaria and angiodemaCutaneous responses such as urticaria and angiodema BronchospasmBronchospasm Large airway obstruction including tongue or throat swelling Large airway obstruction including tongue or throat swelling

and laryngeal edemaand laryngeal edema Hypotension and shockHypotension and shock

Differentials:Differentials: •Foreign bodyForeign body•IV drug useIV drug use•Local infectionLocal infection•CellulitusCellulitus•Vasovagal reactionVasovagal reaction•Asthma Asthma

Treatment PlanTreatment PlanMild Local Reactions:Mild Local Reactions: Remove any remaining stinger by flicking with the edge of a sharp Remove any remaining stinger by flicking with the edge of a sharp

object. DO NOT squeeze the attached venom sac.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 Administer an antihistamine such as Benadryl at 5mg/kg/day

divided every eight hours for pruritus x 24-48 hours.divided every eight hours for pruritus x 24-48 hours. Oral analgesics as needed for discomfortOral analgesics as needed for discomfort Calamine lotion or one part meat tenderizer mixed with four parts Calamine lotion or one part meat tenderizer mixed with four parts

of water to relieve discomfort. of water to relieve discomfort. Elevate extremity Elevate extremity

Large Local Reactions:Large Local Reactions: Add Prednisone 40mg PO to above regimen Add Prednisone 40mg PO to above regimen

and taper over 4-7 daysand taper over 4-7 days

Treatment Plan cont.Treatment Plan cont.Systemic Allergic Reaction:Systemic Allergic Reaction: Epinephrine 0.01mg/kg of 1:1000 aqueous solution IM Epinephrine 0.01mg/kg of 1:1000 aqueous solution IM

repeated at 5-15 minute intervals. repeated at 5-15 minute intervals. (Administer above the sting site.)(Administer above the sting site.)

Antihistamines such as Benadryl or Hydoxyzine Antihistamines such as Benadryl or Hydoxyzine HH22 antagonists such as Cimetidine or Ranitidine antagonists such as Cimetidine or Ranitidine Inhaled bronchodilators such as nebulized Albuterol at Inhaled bronchodilators such as nebulized Albuterol at

20 minute intervals for wheezing and airway 20 minute intervals for wheezing and airway constrictionconstriction

GlucocorticoidsGlucocorticoidsAnd, if severe anaphylaxis,And, if severe anaphylaxis,

maintain airway and maintain airway and call call 911 911 immediately for immediately for

ambulance transport to ER !ambulance transport to ER !

Follow Up and InstructionsFollow Up and Instructions Potential for rebound or late phase anaphylaxis within 6-12 Potential for rebound or late phase anaphylaxis within 6-12

hours after exposurehours after exposure Serum sickness can occur up to 14 days after sting: S/S are Serum sickness can occur up to 14 days after sting: S/S are

fever, arthralgia, lymphadenopathy, skin eruptionsfever, arthralgia, lymphadenopathy, skin eruptions Potential for infection at the sting sitePotential for infection at the sting site Instruct signs and symptoms of infection, serum sickness and Instruct signs and symptoms of infection, serum sickness and

anaphylaxis to reportanaphylaxis 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 Refer for allergy testing with possible RAST and

desensitization-venom immunotherapy (VIT)desensitization-venom immunotherapy (VIT) Rx: Epi-pen and Benadryl and instruct patient in useRx: Epi-pen and Benadryl and instruct patient in use Follow up visit in 24 hours for systemic reaction to stingFollow up visit in 24 hours for systemic reaction to sting Patient usually hospitalized 24 hours for observation in cases Patient usually hospitalized 24 hours for observation in cases

of severe anaphylaxis of severe anaphylaxis

ReferencesReferences1.1. Uphold, C., & Graham, M. (2003). Insect Sting and Brown Recluse Spider Bite. Uphold, C., & Graham, M. (2003). Insect Sting and Brown Recluse Spider Bite.

InIn Clinical Guidelines in Family PracticeClinical Guidelines in Family Practice (pp 950-954). Barmarrae Books, (pp 950-954). Barmarrae Books, Gainesville, FL.Gainesville, FL.

2.2. Tierney, L., McPhee, S., Papadakis, M., (2006), Tierney, L., McPhee, S., Papadakis, M., (2006), Current Medical Diagnosis and Current Medical Diagnosis and TreatmentTreatment, 45th Edition. (pp 791-792). Lange/McGraw-Hill., 45th Edition. (pp 791-792). Lange/McGraw-Hill.

3.3. Burns, C., Dunn, A., Brady, M., Starr, N., Blosser, C., (2004). Burns, C., Dunn, A., Brady, M., Starr, N., Blosser, C., (2004). Pediatric Primary Pediatric Primary CareCare 3rd Edition, (pp 1147-1148). Saunders, St. Louis, MO. 3rd Edition, (pp 1147-1148). Saunders, St. Louis, MO.

4.4. http://http://www.guideline.gov/summary/summary.aspx?doc_idwww.guideline.gov/summary/summary.aspx?doc_id=6888&mode==6888&mode=ful&ssful&ss=15=15 Stinging Insect Hypersensitivity: A Practice Parameter Update. Stinging Insect Hypersensitivity: A Practice Parameter Update. National Guideline Clearinghouse.National Guideline Clearinghouse.

5.5. http://www.emedicine.com/EMERG/topic360.htmhttp://www.emedicine.com/EMERG/topic360.htm Linzer Sr, L., (2/9/06) Linzer Sr, L., (2/9/06) Pediatric Anaphylaxis.Pediatric Anaphylaxis.

6.6. http://www.emedicine.com/EMERG/topic55.htmhttp://www.emedicine.com/EMERG/topic55.htm Vankawala, H., (8/21/06) Bee Vankawala, H., (8/21/06) Bee And Hymenoptra Stings.And Hymenoptra Stings.