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Bee Stings ( H y m e n o p t e r a ). Diagnosis, Treatment, and Management of Systemic Reactions by Deborah Wolff-Baker. Pathophysiology of an allergic reaction.

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bee stings h y m e n o p t e r a

Bee Stings (Hymenoptera)

Diagnosis, Treatment, and Management of

Systemic Reactions

by

Deborah Wolff-Baker

pathophysiology of an allergic reaction
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.
statistics
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
assessment
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!

assessment cont
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
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
treatment plan
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

treatment plan cont
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 !

follow up and instructions
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
references
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.
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