What is the management for a patient with a history of allergic reactions and without, after a bee sting?

Bee Sting Management

For patients with anaphylaxis from a bee sting, immediately administer intramuscular epinephrine 0.3-0.5 mg into the anterolateral thigh and activate emergency medical services—this is the single most critical life-saving intervention. 1, 2

Immediate Management for Anaphylactic Reactions (Patients with History of Allergic Reactions)

Recognition of Anaphylaxis

Anaphylaxis presents with sudden onset (within minutes to 2 hours) of multi-system symptoms: 1

• Skin: Hives, itching, redness, or swelling extending beyond the sting site 1
• Respiratory: Hoarseness, throat tightness, stridor, wheeze, difficulty breathing, chest tightness, or cyanosis 1
• Cardiovascular: Hypotension, tachycardia, syncope 3
• Gastrointestinal: Vomiting, diarrhea, abdominal cramps 3

Critical warning: Laryngeal edema is the most common cause of death from bee sting anaphylaxis, and delay in epinephrine administration is strongly associated with fatal outcomes. 1

Step-by-Step Acute Treatment Algorithm

1. Epinephrine Administration (FIRST-LINE, LIFE-SAVING)

• Inject intramuscularly into the mid-outer thigh (vastus lateralis) immediately upon recognition of anaphylaxis 1, 2
• Adult dose: 0.3-0.5 mg (depending on reaction severity) 1
• Pediatric dose: 0.01 mg/kg (maximum 0.3 mg in prepubertal children, up to 0.5 mg in teenagers) 1, 2
• Intramuscular injection in the anterolateral thigh achieves faster and higher plasma concentrations than subcutaneous or arm injections 1
• Repeat every 5-15 minutes if symptoms persist or worsen 1, 2

2. Call Emergency Services

• Activate EMS immediately after administering epinephrine, without delay 1

3. Remove the Stinger

• Scrape or flick away the stinger immediately with a fingernail or tweezers to prevent additional venom injection 1

4. Patient Positioning

• Position patient supine with legs elevated if hypotension develops to prevent sudden death from "empty-ventricle syndrome" 1

5. Adjunctive Therapies (SECONDARY to epinephrine)

• IV fluids: 1-2 liters normal saline bolus for persistent hypotension (massive fluid shifts occur during anaphylaxis) 1
• Supplemental oxygen: Give to all patients with prolonged reactions, hypoxemia, or requiring multiple epinephrine doses 1, 2
• Inhaled albuterol: 2.5 mg nebulized for bronchospasm persisting despite epinephrine 1
• H1 antihistamines: Diphenhydramine 25-50 mg IV/IM in adults (adjunct only—does NOT treat life-threatening symptoms) 1
• H2 blockers: Ranitidine 50 mg IV or famotidine 20 mg IV (adjunct only) 1
• Corticosteroids: Methylprednisolone 125 mg IV or prednisone 0.5 mg/kg PO to potentially prevent biphasic reactions (no immediate effect) 1

6. Refractory Cases

• For refractory hypotension despite multiple IM doses, transition to intravenous epinephrine infusion 1

Risk Factors for Severe or Fatal Reactions

• Coexisting asthma (especially if severe or poorly controlled) significantly increases risk of severe or fatal reactions 1
• Adolescence is associated with higher fatality rates 1
• Older age and cardiovascular disease increase fatality risk 1
• Mastocytosis is found in 3-5% of patients with sting anaphylaxis, rendering these patients prone to very severe reactions 4

Management for Patients WITHOUT History of Allergic Reactions

Local Reactions Only

For patients experiencing only local pain, swelling, and erythema at the sting site without systemic symptoms:

• Remove the stinger immediately by scraping or flicking 1
• Cold compresses to reduce local pain and swelling 5
• Oral antihistamines to reduce itching and pain 5
• Monitor closely for development of systemic symptoms (anaphylaxis can occur within minutes to 2 hours) 1

Large Local Reactions

Large local reactions are IgE-mediated allergic responses causing swelling that peaks at 24-48 hours and lasts up to a week, affecting 5-15% of the population: 5

• Cold compresses for pain and swelling 5
• Oral antihistamines for itching and pain 5
• Oral corticosteroids may be used for severe large local reactions 5

Critical pitfall: Avoid mistaking allergic swelling and lymphangitis for bacterial cellulitis—the swelling is caused by allergic inflammation and mediator release, NOT bacterial infection. 5 Antibiotics are NOT indicated unless there is clear evidence of secondary bacterial infection (purulent drainage, fever, or progressive worsening beyond 48-72 hours despite anti-inflammatory treatment). 5

Post-Event Management and Prevention

For ALL Patients with Systemic Reactions (Grade ≥ II)

1. Prescribe Epinephrine Autoinjector

• Prescribe EpiPen or equivalent before discharge and demonstrate proper use 1, 2
• Patients with history of grade ≥ III reaction, or grade II with additional risk factors, should carry an emergency kit including an AAI during and after venom immunotherapy 4

2. Measure Baseline Serum Tryptase

• If systemic allergic reaction extends beyond the skin (grade > I), measure baseline serum tryptase concentration and examine skin for possible mastocytosis 4

3. Allergist Referral (MANDATORY)

• Refer ALL patients with systemic reactions to an allergist-immunologist for comprehensive evaluation and venom immunotherapy (VIT) consideration 1, 2
• Venom-specific IgE testing should be performed 4
• If results are negative less than 2 weeks after the sting, repeat testing at least 4-6 weeks after the sting 4

4. Venom Immunotherapy (VIT)

• VIT is indicated for patients with history of systemic reactions beyond isolated cutaneous manifestations 2, 4
• VIT can reduce the risk of future systemic reactions from 25-70% to less than 5% (nearly zero) 1, 2
• Standard maintenance dose is 100 µg HV; in adult patients with bee venom allergy and increased risk, 200 µg can be considered 4
• Maintenance dose given at 4-weekly intervals during first year, then every 5-6 weeks from second year 4
• VIT can be discontinued after 3-5 years in patients without specific risk factors 4
• Prolonged or permanent VIT should be considered in patients with mastocytosis, history of cardiovascular or respiratory arrest (severity grade IV), or other specific constellations associated with increased risk 4

Avoidance Education

Educate on trigger avoidance: 1, 2

• Avoid walking barefoot outdoors
• Wear protective clothing
• Avoid bright colors and floral patterns
• Eliminate scented products
• Have nests professionally removed