What is the initial treatment and workup for a 4-year-old patient presenting with a swollen eye due to a bee sting, specifically Hymenoptera (insect) envenomation?

From the Guidelines

For a 4-year-old with a swollen eye from a bee sting, the initial treatment and workup should prioritize immediate removal of the stinger, administration of epinephrine if signs of anaphylaxis are present, and careful examination for ocular injuries, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. The initial steps in management should include:

• Removing the stinger immediately if still present, by scraping it off with a credit card or fingernail, as this can help reduce the amount of venom delivered 1.
• Applying a cold compress to reduce swelling and pain, which can help alleviate local symptoms 1.
• Assessing for signs of anaphylaxis, such as difficulty breathing, widespread hives, or dizziness, and administering epinephrine if present, as it is the drug of choice for the treatment of anaphylaxis 1.
• Examining the eye for corneal involvement or other ocular injuries, as stings to the eye can lead to permanent vision loss and require immediate medical attention 1. Additional management may include:
• Administering oral antihistamine, such as Diphenhydramine (Benadryl), to alleviate local itching and reduce the allergic response 1.
• Giving acetaminophen for pain relief, as it can help alleviate local pain 1.
• Considering oral prednisone for significant swelling that persists, as it can help reduce inflammation 1.
• Instructing parents to watch for signs of infection, such as increased redness, warmth, or pus, over the next 48 hours, and advising follow-up with a primary care provider if symptoms worsen or do not improve within 2-3 days 1.

From the FDA Drug Label

Emergency treatment of allergic reactions (Type I), including anaphylaxis, which may result from allergic reactions to insect stings, biting insects, foods, drugs, sera, diagnostic testing substances and other allergens, as well as idiopathic anaphylaxis or exercise-induced anaphylaxis. The signs and symptoms associated with anaphylaxis include flushing, apprehension, syncope, tachycardia, thready or unobtainable pulse associated with hypotension, convulsions, vomiting, diarrhea and abdominal cramps, involuntary voiding, airway swelling, laryngospasm, bronchospasm, pruritus, urticaria or angioedema, swelling of the eyelids, lips, and tongue.

The initial treatment for a 4-year-old patient presenting with a swollen eye due to a bee sting, specifically Hymenoptera (insect) envenomation, may involve administering epinephrine (IM) if the patient is showing signs of anaphylaxis, such as:

• Airway swelling
• Laryngospasm
• Bronchospasm
• Urticaria or angioedema
• Swelling of the eyelids, lips, and tongue 2

From the Research

Initial Treatment and Workup

The initial treatment and workup for a 4-year-old patient presenting with a swollen eye due to a bee sting, specifically Hymenoptera (insect) envenomation, may involve the following steps:

• Assessment of the patient's overall condition and vital signs
• Evaluation of the affected eye, including visual acuity and intraocular pressure
• Examination for signs of anaphylaxis or other systemic reactions
• Administration of antihistamines, corticosteroids, or epinephrine as needed to manage allergic reactions or anaphylaxis 3
• Monitoring for potential complications, such as skin necrosis, rhabdomyolysis, or renal failure, which can occur with massive inoculation of venom

Diagnostic Considerations

In addition to the initial treatment, the following diagnostic considerations may be relevant:

• Laboratory studies, such as urinalysis or serum albumin, to rule out other potential causes of swelling, such as nephrotic syndrome 4
• Imaging studies, such as fluorescein angiography, to evaluate the retina and rule out conditions like occlusive retinal vasculitis 5
• Careful history taking and physical examination to identify potential underlying conditions or contributing factors

Management of Potential Complications

The management of potential complications, such as anaphylaxis or toxic reactions, may involve:

• Administration of medications, such as epinephrine or antihistamines, to manage allergic reactions or anaphylaxis
• Monitoring of vital signs and overall condition to quickly identify any potential complications
• Referral to a pediatric intensive care unit (PICU) if necessary, as in the case of generalized tetanus infection 6