Treatment of Anaphylactic Shock from Bee Sting
Immediately administer intramuscular epinephrine 0.3-0.5 mg in adults (0.01 mg/kg up to 0.3 mg in children) into the anterolateral thigh and activate emergency medical services—this is the single most critical intervention that saves lives. 1, 2
Immediate Actions (First 60 Seconds)
Remove the stinger immediately by scraping or flicking it away with a fingernail—do not grasp the venom sac as this injects additional venom, and the stinger can continue delivering venom for up to 60 seconds 1
Administer epinephrine via intramuscular injection in the anterolateral thigh (not subcutaneous, not in the arm) as this route achieves faster and higher plasma concentrations 1, 3
Call 911 immediately after administering epinephrine—do not delay emergency activation 1, 3
Position the patient supine with legs elevated if hypotension develops, as raising patients from supine to upright during anaphylactic shock can cause sudden death from "empty-ventricle syndrome" 1, 3
Repeat Dosing and Escalation
Be prepared to repeat epinephrine every 5 minutes if symptoms persist or worsen—delayed or inadequate epinephrine use is associated with fatal outcomes 1, 3
For refractory hypotension despite multiple IM doses, transition to intravenous epinephrine infusion: add 1 mg epinephrine to 250 mL D5W (yielding 4 mcg/mL) and infuse at 1-4 mcg/min, titrating up to 10 mcg/min in adults 1
Administer 1-2 liters of IV normal saline bolus for persistent hypotension, as massive fluid shifts occur during anaphylaxis 1
Adjunctive Treatments (Not Substitutes for Epinephrine)
Administer supplemental oxygen to all patients with prolonged reactions, hypoxemia, or requiring multiple epinephrine doses 1
Give inhaled albuterol (2.5 mg nebulized) for bronchospasm that persists despite epinephrine 1
Administer H1 antihistamines (diphenhydramine 25-50 mg IV/IM in adults) and H2 blockers (ranitidine 50 mg IV or famotidine 20 mg IV) as adjuncts, but these do not treat life-threatening symptoms 1, 4
Give corticosteroids (methylprednisolone 125 mg IV or prednisone 0.5 mg/kg PO) to potentially prevent biphasic reactions, though they have no immediate effect 1
Critical Pitfalls to Avoid
Never delay epinephrine administration—antihistamines and corticosteroids are not substitutes and delayed epinephrine is associated with fatal outcomes 1, 4
Do not assume the reaction is over after initial improvement—biphasic reactions can occur hours later, though mandatory observation periods are not evidence-based as reactions can occur outside typical windows 1, 5
Do not use subcutaneous epinephrine or inject in the arm—intramuscular injection in the thigh is superior 1, 3
Avoid raising the patient to upright position during shock—maintain supine position with legs elevated 1
Special Circumstances
Eye stings require immediate ophthalmology evaluation as they can cause permanent vision loss 1, 3
Multiple stings (>100) can cause toxic reactions from massive envenomation that mimic anaphylaxis but result from direct venom effects rather than allergic mechanisms 1, 3
Patients on beta-blockers may be refractory to epinephrine and require higher doses or alternative vasopressors like glucagon 1
There are no contraindications to epinephrine in anaphylaxis—even patients with cardiovascular disease should receive it as the benefits far outweigh risks 1, 6
Disposition and Follow-Up
Prescribe epinephrine autoinjector (EpiPen or equivalent) before discharge and demonstrate proper use 1, 3
Refer all patients to an allergist-immunologist for venom-specific IgE testing and consideration of venom immunotherapy, which dramatically reduces risk of future anaphylaxis 1, 3
Educate on trigger avoidance: avoid walking barefoot outdoors, wear protective clothing, avoid bright colors and floral patterns, eliminate scented products, and have nests professionally removed 3