What is the emergency department management for a bee sting to the back of the throat?

Emergency Department Management of Bee Sting to the Back of Throat

Immediate airway management with endotracheal intubation is recommended for bee stings to the back of the throat, even in patients with minimal initial symptoms, due to the high risk of life-threatening airway obstruction from local swelling. 1

Initial Assessment and Management

• Assess for signs of airway compromise including difficulty breathing, tongue/throat swelling, dysphonia, odynophagia, and drooling 2
• Remove the stinger as quickly as possible if visible, using tweezers or by scraping, as venom can continue to be delivered for up to 60 seconds 3
• Administer parenteral epinephrine immediately, even with minimal initial symptoms, as oropharyngeal stings can rapidly progress to airway obstruction 1, 2
• Secure the airway with endotracheal intubation and provide mechanical ventilation for at least 24 hours in patients with any signs of airway compromise 1
• Consider preventive intubation even in patients with minimal symptoms due to the risk of delayed airway edema 1

Pharmacological Management

• Administer epinephrine 0.01 mg/kg (up to 0.3 mg) in children and 0.3-0.5 mg in adults via intramuscular injection in the anterolateral thigh 4, 5
• Give intravenous corticosteroids (e.g., methylprednisolone) to reduce inflammation and swelling 1, 2
• Administer antihistamines (H1 blockers such as diphenhydramine) to help control allergic response 1, 2
• Provide inhalational bronchodilators if bronchospasm is present 1

Monitoring and Observation

• All patients with bee stings to the back of throat require close monitoring in a critical care setting for at least 24 hours 1
• Monitor for signs of anaphylaxis including hypotension, tachycardia, bronchospasm, and skin manifestations 5
• Be prepared for rapid deterioration, as laryngeal edema is the most common cause of death from Hymenoptera-induced anaphylaxis 3
• Continue monitoring even after initial improvement, as delayed reactions can occur 6

Discharge Planning

• Prescribe epinephrine auto-injector for all patients with history of systemic reaction to insect sting 3, 4
• Educate patient on avoidance of stinging insects 3
• Consider referral to an allergist-immunologist for venom-specific IgE testing and possible venom immunotherapy 3
• Provide clear instructions on when to seek emergency care if symptoms recur 4

Special Considerations

• Patients with mastocytosis are at higher risk for severe reactions and may require more aggressive management 6
• Multiple stings increase risk of toxic reactions due to massive envenomation 3, 4
• Venom immunotherapy should be considered for patients with history of systemic reactions to reduce risk of future anaphylaxis 3, 6

Pitfalls to Avoid

• Delaying airway management can lead to fatal outcomes - do not wait for severe symptoms to develop before securing the airway 1, 2
• Failing to remove the stinger promptly can result in continued envenomation 3
• Mistaking swelling for infection and inappropriately prescribing antibiotics instead of focusing on anti-inflammatory treatment 3
• Discharging patients too early, as delayed reactions can occur hours after the initial sting 2, 6
• Underestimating the severity of throat stings compared to cutaneous stings 1, 2