What is the assessment and management approach for an 8-year-old patient presenting to the emergency room (ER) 2 days after a bee sting to the left eye?

Assessment and Management of Bee Sting to the Left Eye in an 8-Year-Old

Initial Assessment Checklist for ER Evaluation

The most important initial step in managing an 8-year-old with a bee sting to the left eye is to perform a thorough ocular examination to identify any retained stinger and assess for signs of infection or allergic reaction, followed by appropriate removal of any foreign body and administration of topical and systemic medications as indicated. 1

Primary Assessment

• Vital signs: Temperature, heart rate, respiratory rate, blood pressure, oxygen saturation
• ABCs: Assess airway, breathing, circulation 2
• Systemic symptoms: Check for signs of anaphylaxis (urticaria, angioedema, respiratory distress, hypotension) 2, 3

Ocular Examination

1. Visual acuity assessment: Document baseline vision in both eyes
2. External examination:
   • Eyelid inspection for edema, erythema, and retained stinger
   • Eyelid eversion to check for hidden stinger 4
   • Periorbital assessment for swelling, redness, warmth
3. Slit lamp examination:
   • Conjunctival inspection for hyperemia, chemosis, foreign body
   • Corneal evaluation for abrasions, infiltrates, or embedded stinger 5, 6
   • Anterior chamber assessment for inflammation (cells, flare, hypopyon) 5
4. Posterior segment examination:
   • Dilated fundus examination to rule out posterior segment involvement
   • Check for signs of optic nerve involvement 5

Red Flags to Watch For

Ocular Red Flags

• Retained stinger in eye (cornea, conjunctiva, or eyelid) 6, 7, 4
• Corneal infiltrate or ulceration 5
• Anterior chamber reaction (cells, flare, hypopyon) 5, 8
• Elevated intraocular pressure
• Decreased visual acuity
• Signs of endophthalmitis (severe pain, decreased vision, hypopyon) 8
• Optic nerve involvement 5

Systemic Red Flags

• Signs of anaphylaxis:
  • Respiratory distress (wheezing, stridor)
  • Cardiovascular compromise (hypotension, tachycardia)
  • Widespread urticaria
  • Angioedema 2, 3
• Fever (suggesting infection)
• Altered mental status

Management Protocol

Immediate Management

1. If anaphylaxis is present:

   • Administer epinephrine intramuscularly in mid-outer thigh (0.01 mg/kg up to 0.3 mg) 1, 3
   • Place patient supine with legs elevated if experiencing cardiovascular symptoms 1
   • Establish IV access for fluid resuscitation with normal saline 1
   • Administer oxygen if needed 1

2. For retained stinger:

   • Carefully remove any visible stinger using fine forceps 6, 7
   • Irrigation of the eye with sterile saline 1

3. For ocular inflammation:

   • Topical corticosteroids (prednisolone acetate 1%) 5, 6
   • Topical antibiotics (broad-spectrum) to prevent secondary infection 5, 6, 7
   • Consider cycloplegic agents (cyclopentolate 1%) to reduce pain and prevent synechiae formation 6

Systemic Therapy

1. Oral antihistamines:

   • Non-sedating second-generation antihistamines (loratadine 10 mg daily) for daytime use 1
   • First-generation antihistamines (diphenhydramine 1 mg/kg) for nighttime use if needed 1

2. Systemic corticosteroids:

   • Consider methylprednisolone 1-2 mg/kg IV or oral equivalent for significant inflammation 1

3. Antibiotics:

   • Consider systemic antibiotics if signs of infection are present or if there is corneal infiltration 1, 8

Follow-up Care

1. Short-term follow-up:

   • Re-evaluation within 24-48 hours to assess response to treatment
   • Monitor for development of infection or endophthalmitis 8

2. Patient/parent education:

   • Warning signs requiring immediate return (increased pain, decreased vision, worsening redness)
   • Proper administration of prescribed medications
   • Potential for recurrence of symptoms 3

3. Long-term considerations:

   • Regular follow-up until complete resolution
   • Monitor for late complications (cataract, iris atrophy, optic neuropathy) 5

Special Considerations for Pediatric Patients

• Age-appropriate pain management
• Consider sedation for thorough examination if needed
• Ensure compliance with medication through parent education
• Psychological support for traumatic eye injury

Documentation

• Use a treatment log to record interventions and timing 2
• Document visual acuity before and after treatment
• Record all medications administered and their dosages
• Note any procedures performed (stinger removal, etc.)

Remember that while most ocular bee stings have a good prognosis with appropriate treatment, severe complications including endophthalmitis and vision loss can occur if not managed properly 5, 8. Early identification and removal of any retained stinger along with aggressive anti-inflammatory treatment are essential for preventing long-term complications.