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Multiple honeybee stings normotensive with tachycardia

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"Bees"[MeSH Terms] AND "Bites and Stings"[MeSH Terms]

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multiple honeybee stings management mass envenomation anaphylaxis vs toxic reaction

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Multiple honeybee stings in a normotensive patient with tachycardia: assessment and management
Normotension with tachycardia does not exclude serious disease. It can be early compensated anaphylaxis, the start of systemic venom toxicity, or just pain and anxiety. Treat it as potentially serious until you have excluded the first two.
1. Is it allergic or toxic?
FeatureAnaphylaxis (IgE)Toxic envenomation (dose-related)
Number of stingsCan follow a single stingUsually many (see below)
OnsetMinutes, mostly within 30 minHours, with organ injury over 24-72 h
FeaturesUrticaria, angioedema, wheeze, stridor, vomiting, hypotensionNausea, vomiting, diarrhoea, tachycardia, hemolysis, rhabdomyolysis, AKI, hepatic injury, bleeding
  • Allergic reactions are usually the main concern after hymenoptera stings. Clinically significant direct toxicity usually needs a massive number of stings. Most serious reactions occur in the first 30 minutes. - ROSEN's Emergency Medicine, p. 819
  • Moderate envenomation (about 50 to 200 stings) typically causes nausea, vomiting, anxiety, tachycardia, hypertension, rhabdomyolysis and kidney injury. Hundreds of stings can lead to multiorgan failure over the following days. - ROSEN's Emergency Medicine, p. 819
  • Hundreds of simultaneous stings cause intravascular hemolysis, rhabdomyolysis, bleeding, cardiovascular, hepatic and pulmonary injury, and severe AKI, with high mortality. - Comprehensive Clinical Nephrology, 7th Ed.
  • Tachycardia alone with preserved blood pressure fits either early toxicity or early anaphylaxis. Reassess often, because BP can fall suddenly.
  • A rough rule from other sources: observe anyone with more than 50 stings for both anaphylaxis and toxic envenomation. Systemic toxicity usually follows about 500 or more stings. See the DermNet NZ summary.
2. Immediate management
  1. ABCs and monitoring. Give oxygen if needed, place IV access and start continuous cardiac monitoring. Check the airway for lip, tongue or throat swelling and for wheeze.
  2. Remove stingers. Do this early by scraping with a blade, fingernail or card edge, or with forceps. Then cleanse the skin and apply ice and elevation. - Harrison's Principles of Internal Medicine, 22nd Ed., p. 3778
    • Speed matters more than the method. Some sources note that removal later in the course does little to reduce the venom dose.
  3. Give IM epinephrine at the first sign of anaphylaxis. Signs include skin and mucosal involvement with respiratory, GI or hemodynamic compromise. Standard dose is 0.3 to 0.5 mg of 1:1000 into the anterolateral thigh, repeated every 5 to 15 minutes if needed.
    • Harrison's describes subcutaneous dosing every 20 to 30 minutes. Current anaphylaxis guidance favors the IM route, so I have used that instead.
    • Add IV fluids, bronchodilators, antihistamines and steroids as adjuncts only. They do not replace epinephrine.
  4. Symptomatic care. Give analgesia and oral or IV antihistamines for itch and local symptoms.
3. Investigations for multiple stings
  • ECG and troponin. MI and Kounis syndrome (allergic acute coronary syndrome) are described after bee stings.
  • CK. Levels can reach 100,000 IU/L or more with rhabdomyolysis. - Tintinalli's Emergency Medicine
  • Creatinine, electrolytes (potassium, calcium), urinalysis for myoglobin and hemoglobin, and urine output.
  • CBC and peripheral smear, LDH, bilirubin and haptoglobin for hemolysis.
  • LFTs, PT/INR, fibrinogen and platelets, since DIC and thrombotic microangiopathy (TMA) can occur.
  • Blood gas and lactate.
4. Supportive care and disposition
  • Give aggressive IV crystalloid to protect the kidneys and treat rhabdomyolysis. Aim for good urine output, and monitor for fluid overload if the lungs or kidneys are involved.
  • Observe for 24 hours or longer. Harrison's advises watching for recurrent anaphylaxis, renal failure and coagulopathy. - Harrison's, p. 3779
  • Consider ICU admission for any of these:
    • Hundreds of stings
    • Hemodynamic instability
    • Rising CK or creatinine
    • Hemolysis or coagulopathy
    • Altered mental status
  • Renal replacement therapy is for standard indications. Plasma exchange has been used in case reports for severe cases. Evidence is limited, so I would not call it routine.
  • No antivenom is approved for human use. One has been developed that protected against rhabdomyolysis and hemolysis in mice.
5. Follow-up
If anaphylaxis occurred, prescribe an epinephrine auto-injector and refer to an allergist for venom immunotherapy. - Harrison's, p. 3779
Recent literature
A quick PubMed check of the last two years found nothing that contradicts the above. It did find systematic reviews of bee-sting-associated myocardial infarction or Kounis syndrome (PMID 41299289, PMID 42873993) and of stroke after bee or wasp stings (PMID 40927590). They support getting an ECG and troponin in any tachycardic patient with multiple stings.
I can add the specific sting count, patient age, comorbidities, or local lab results if you want the plan tailored.
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