Epinephrine Dosage for Bee Sting Anaphylaxis
For anaphylaxis from a bee sting, administer epinephrine 0.3-0.5 mg intramuscularly in adults (0.01 mg/kg up to 0.3 mg maximum in children) into the anterolateral thigh immediately—this is the only first-line treatment that saves lives. 1, 2, 3
Specific Dosing by Age and Weight
Adults and Children ≥30 kg (66 lbs)
- Dose: 0.3 to 0.5 mg (0.3 to 0.5 mL of 1:1000 solution) intramuscularly 1, 3
- Route: Anterolateral thigh (vastus lateralis muscle) 1, 3
- Timing: Immediately upon recognition of anaphylaxis symptoms 2, 4
Children <30 kg (66 lbs)
- Dose: 0.01 mg/kg (0.01 mL/kg of 1:1000 solution), maximum 0.3 mg 1, 3
- Route: Anterolateral thigh (vastus lateralis muscle) 1, 3
Critical Administration Details
Why the Thigh Route Matters
- Intramuscular injection in the anterolateral thigh achieves more rapid and higher plasma concentrations than subcutaneous injection or intramuscular injection in the arm 1, 2
- Never inject into the buttocks, digits, hands, or feet due to risk of tissue necrosis and delayed absorption 3
Repeat Dosing Protocol
- Repeat the same dose every 5-10 minutes if symptoms persist or worsen 2, 3
- Most patients require only 1-2 doses, but some need 3 or more 2
- Delayed or inadequate epinephrine administration is directly associated with fatal outcomes 1, 2
Immediate Concurrent Actions
First 60 Seconds
- Remove the stinger within 10-20 seconds by scraping or flicking it away with a fingernail (never grasp and pull the venom sac) 2, 5
- Inject epinephrine immediately 2
- Call emergency services without delay 2
- Position patient supine with legs elevated if hypotension develops 2
Adjunctive Medications (Second-Line Only)
- H1 antihistamine: Diphenhydramine 25-50 mg IV/IM in adults (1-2 mg/kg in children) 1, 2
- H2 blocker: Ranitidine 50 mg IV or famotidine 20 mg IV 1, 2
- Corticosteroids: Methylprednisolone 125 mg IV or prednisone 0.5 mg/kg PO to prevent biphasic reactions 1, 2
- Bronchodilator: Albuterol 2.5-5 mg nebulized if bronchospasm persists despite epinephrine 1, 2
Critical caveat: Antihistamines and corticosteroids are NOT substitutes for epinephrine and should never be used alone or delay epinephrine administration 1, 2
Refractory Cases Requiring Escalation
When Multiple IM Doses Fail
- Transition to intravenous epinephrine infusion: 1 mg epinephrine in 250 mL D5W, infused at 1-4 mcg/min, titrating up to 10 mcg/min 1, 2
- Pediatric IV dosing: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution; maximum 0.3 mg) 1
- Only use IV epinephrine for cardiac arrest or profound hypotension unresponsive to IM doses and fluid resuscitation 1, 2
- Administer 1-2 liters IV normal saline bolus for persistent hypotension 2
Special Populations Requiring Modified Approach
- Patients on beta-blockers: May be refractory to epinephrine; consider glucagon 1-5 mg IV over 5 minutes followed by infusion (5-15 mcg/min) 1, 2
- Cardiovascular disease: There are NO contraindications to epinephrine in anaphylaxis—the benefits far outweigh risks even in patients with heart disease or arrhythmias 1, 3
Common Pitfalls to Avoid
- Never delay epinephrine while giving antihistamines or corticosteroids first—this delay kills patients 1, 2
- Never use subcutaneous epinephrine instead of intramuscular—absorption is too slow 1, 4
- Never inject in the arm instead of the thigh—plasma levels are inadequate 1, 2
- Never assume the reaction is over after initial improvement—biphasic reactions occur hours later in some cases 1, 2
- Never withhold epinephrine due to cardiovascular concerns—anaphylaxis itself is more dangerous than epinephrine's cardiac effects 1
Post-Emergency Management
Before Discharge
- Prescribe epinephrine autoinjector (EpiPen or equivalent) and demonstrate proper use to patient/caregivers 1, 2, 5
- Refer to allergist-immunologist for venom-specific IgE testing 1, 2, 5
- Consider venom immunotherapy (VIT), which dramatically reduces future anaphylaxis risk 2, 5