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Bee Sting Case Management: Emergency → IPD → Discharge

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1. TRIAGE & INITIAL ASSESSMENT (Emergency Department)

Classify the Reaction First

Serum tryptase measured early in the reaction provides evidence of anaphylaxis if levels are elevated or significantly increased from basal level (Stinging Insect Hypersensitivity, p. 13).

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2. EMERGENCY MANAGEMENT

A. Anaphylaxis Protocol (First Priority)

1. Remove stinger immediately — scrape, do not squeeze (reduces further venom injection)
2. Epinephrine (adrenaline) — FIRST-LINE, no contraindications
   • IM epinephrine 0.3–0.5 mg (0.3 mL of 1:1000) into anterolateral thigh
   • Repeat every 5–15 min if no improvement
   • If individual has a bee-sting kit, use subcutaneous epinephrine 0.3 mL of 1:1000, repeated every 20–30 min (Harrison's, p. 13104)
3. Position: Supine with legs elevated (unless respiratory distress → semi-recumbent)
4. IV access × 2 + O₂ (high-flow 10–15 L/min via non-rebreather mask)
5. Fluid resuscitation: IV crystalloid (Normal saline) 1–2 L bolus for hypotension/shock

B. Adjunct Pharmacotherapy

IV epinephrine and other vasopressors, intubation/supplemental oxygen, fluid resuscitation, bronchodilators, and parenteral antihistamines are the mainstay of profound shock management (Harrison's, p. 13104).

C. Airway Management

• Early intubation if stridor, voice change, or rapidly progressing angioedema
• Have surgical airway (cricothyrotomy) kit at bedside

D. Toxic / Massive Envenomation (>50–100 stings)

• Treat as medical emergency with full resuscitation
• Anticipate: haemolysis, rhabdomyolysis, AKI, DIC, hepatic injury, cardiac arrhythmias
• IV hydration: aggressive fluid loading (2–3 mL/kg/h) to maintain UO ≥1 mL/kg/h
• Urinary alkalinisation (sodium bicarbonate) if myoglobinuria present
• Monitor ECG continuously

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3. MONITORING IN EMERGENCY (Observation Period)

Patients should be observed for 24 h for recurrent anaphylaxis, renal failure, or coagulopathy (Harrison's, p. 13104).

Biphasic Anaphylaxis

• Occurs in 5–20% of cases, typically 1–8 hours after initial resolution
• Reason for mandatory observation even after clinical improvement

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4. CRITERIA FOR INPATIENT ADMISSION (IPD)

• Severe anaphylaxis requiring IV epinephrine or vasopressors
• Persistent bronchospasm or hypoxia despite treatment
• Angioedema of airway (actual or threatened)
• Cardiovascular compromise
• Multiple stings (toxic envenomation)
• Renal impairment (↑ creatinine, haematuria, oliguria)
• Suspected haemolysis or rhabdomyolysis
• Biphasic reaction
• Comorbidities: cardiac disease, COPD, elderly, on beta-blockers
• Inadequate home situation / inability to access emergency care

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5. IPD MANAGEMENT

A. Monitoring

B. Ongoing Pharmacotherapy

• Continue IV corticosteroids (methylprednisolone 1–2 mg/kg/day or hydrocortisone 100–200 mg QID) for 24–48 h to suppress biphasic and late-phase reactions
• Oral antihistamine continuation (cetirizine 10 mg OD or loratadine 10 mg OD)
• IV fluids — guided by renal function and UO
• If renal failure develops: nephrology consult, possible haemodialysis
• DIC: FFP, cryoprecipitate, platelets as indicated

C. Specific Organ Complication Management

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6. CRITERIA FOR DISCHARGE

• Haemodynamically stable ≥24 h off IV medications
• Airway clear, no stridor or bronchospasm
• Tolerating oral intake
• Renal function normal or improving/stable
• No active bleeding/coagulopathy
• Patient educated and has written action plan

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7. ON-DISCHARGE MANAGEMENT

A. Prescriptions at Discharge

B. Patient & Caregiver Education

1. Avoid bee/wasp habitats — disturbing hives, working in gardens without protection
2. Wear protective clothing outdoors; avoid floral perfumes
3. Carry 2 EpiPen auto-injectors at all times
4. How to use EpiPen — demonstrate and provide written instructions
5. When to call emergency services — any systemic symptoms after a sting
6. Stinger removal — scrape with a card, do not squeeze
7. Recognition of early anaphylaxis signs: urticaria, throat tightness, dizziness, vomiting

C. Follow-Up Plan

D. Venom Immunotherapy (VIT) — Discharge Counselling

• VIT is highly effective — reduces risk of systemic reaction on re-sting from ~60% to <5%
• Indicated after systemic anaphylaxis in adults; consider in children with severe reactions
• Not typically required for large local reactions alone
• Consists of subcutaneous venom injections over 3–5 years
• Referral to allergist at discharge is standard of care

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Summary Flow Chart

BEE STING
    │
    ▼
Classify Reaction
    ├── Local only ──► Analgesia, antihistamine, observe 30 min, discharge
    ├── Large local ──► Antihistamine + corticosteroid, observe 4–6 h, discharge with EpiPen
    │
    └── Systemic / Anaphylaxis / Toxic
              │
              ▼
         EMERGENCY
         IM Epinephrine → Fluids → O₂ → Adjuncts → Observe 24 h
              │
              ▼
         ADMIT (IPD) if criteria met
         Monitoring + IV corticosteroids + Organ support
              │
              ▼
         DISCHARGE when stable
         EpiPen × 2 + Prednisolone taper + Antihistamine
         Allergist referral → Venom Immunotherapy

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• Harrison's Principles of Internal Medicine, 21st Edition, p. 13104
• Stinging Insect Hypersensitivity (GLGCA), p. 13
• WAO/EAACI Anaphylaxis Guidelines; ASCIA Hymenoptera Venom Allergy Guidelines