What is the appropriate management for a 7-year-old male presenting with a hymenoptera (bee) sting to his right foot?

From the Guidelines

For a 7-year-old male with a bee sting to the right foot, first assess for signs of a severe allergic reaction (anaphylaxis) such as difficulty breathing, swelling of the face/throat, hives beyond the sting site, vomiting, or dizziness, which would require immediate emergency care, as stated in the 2024 American Heart Association and American Red Cross guidelines for first aid 1. If no severe reaction is present, the following steps can be taken:

• Remove the stinger by scraping it off with a credit card or fingernail (don't use tweezers as squeezing can release more venom), as recommended by the 2024 guidelines 1.
• Clean the area with soap and water, then apply a cold compress for 20 minutes to reduce swelling and pain.
• Give weight-appropriate acetaminophen (10-15 mg/kg every 4-6 hours) or ibuprofen (5-10 mg/kg every 6-8 hours) for pain relief, as suggested by the guidelines 1.
• Apply a thin layer of 1% hydrocortisone cream and oral diphenhydramine (Benadryl) at 1-2 mg/kg every 6 hours (maximum 50 mg/dose) to manage local allergic symptoms.
• Elevate the foot to reduce swelling.
• Monitor the site for increasing redness, warmth, or swelling which could indicate infection. It is essential to note that most bee stings resolve within hours to days with these measures, but parents should be educated about signs of delayed allergic reactions and advised to seek immediate medical attention if they occur, as emphasized in the 2020 practice parameter update on anaphylaxis 1. Additionally, the 2011 practice parameter update on stinging insect hypersensitivity highlights the importance of epinephrine administration in cases of anaphylaxis, which should be considered in severe reactions 1. However, the most recent and highest quality study, the 2024 American Heart Association and American Red Cross guidelines for first aid 1, should be prioritized in guiding management decisions.

From the FDA Drug Label

Do not inject into digits, hands, or feet. Epinephrine is a strong vasoconstrictor. Accidental injection into the digits, hands or feet may result in loss of blood flow to the affected area and has been associated with tissue necrosis.

The patient has a bee sting on his right foot. Epinephrine injection is not recommended in this area due to the risk of tissue necrosis.

• Look for signs of anaphylaxis, such as difficulty breathing, swelling, or rapid heartbeat.
• Monitor the patient for any signs of infection, such as persistent redness, warmth, swelling, or tenderness, at the site of the bee sting.
• Consider alternative treatments for the bee sting, such as antihistamines or corticosteroids, under the guidance of a medical professional 2.

From the Research

Assessment and Management of Bee Sting

• The patient should be assessed for symptoms of anaphylaxis, such as urticaria, difficulty breathing, and mucosal swelling 3, 4
• The incidence of anaphylaxis in the United States is 2.1 per 1,000 person-years, and most anaphylactic reactions occur outside the hospital setting 3
• Coexisting asthma, mast cell disorders, and underlying cardiovascular disease are associated with severe or fatal anaphylactic reactions 3

Treatment and Monitoring

• Removal of the trigger (in this case, the bee sting) and early administration of intramuscular epinephrine are crucial in managing anaphylaxis 3, 5
• Supportive care for the patient's airway, breathing, and circulation should be provided, and the patient should be monitored for potential biphasic reactions 3, 4
• Patients should be monitored for a biphasic reaction for four to 12 hours, depending on risk factors for severe anaphylaxis 3

Potential Complications

• Cardiac symptoms after epinephrine administration, such as myocardial ischemia, can occur, especially if the epinephrine is administered intravenously rather than intramuscularly 6
• Anaphylaxis-related coronary ischemia (Kounis) syndrome is a potential complication of anaphylaxis 6

Guidelines and Recommendations

• The European Academy of Allergy and Clinical Immunology Anaphylaxis multidisciplinary Task Force recommends the use of clinical criteria to identify anaphylaxis and the prompt use of intramuscular adrenaline as first-line management 5
• Structured, comprehensive training for people at risk of anaphylaxis is recommended, and simulation training and visual prompts for healthcare professionals can improve the management of anaphylaxis 5