eMedicine Specialties > Emergency Medicine > Environmental

Hymenoptera Stings: Follow-up

Author: Hemant H Vankawala, MD, Attending Physician, 24 Hour Emergency Room, Houston and Dallas; Attending Physician, Baylor University Medical Center; Medical Director, Big Bend National Park; Medical Director, Terlingua Fire and EMS; Medical Director, MedCare Ambulance Company
Coauthor(s): Randy Park, MD, Chair, Associate Professor, Department of Emergency Medicine, Denton Regional Medical Center
Contributor Information and Disclosures

Updated: Apr 9, 2009

Follow-up

Further Inpatient Care

  • Consider further inpatient care for all patients with life-threatening reactions.
  • Observe for sufficient duration to ensure symptoms do not rebound after initial treatment. Rebound phenomena may occur up to 12 hours after sting.
  • Respiratory and circulatory support may be needed if secondary organ damage has occurred.

Further Outpatient Care

  • Refer all patients with generalized reactions for allergy testing and desensitization, if indicated.
  • Provide means to self-administer epinephrine and diphenhydramine to all patients with generalized reactions, and advise them to wear medic alert bracelets.
  • Continue treatment with steroids in the ED for 3-5 days.
  • Continue administering antihistamines for at least 24 hours continuous dosing.
  • Cool sting sites for 12 hours.
  • Keep extremities with stings elevated for 12 hours when development of edema may present difficulties.

Deterrence/Prevention

  • Avoiding stings is vitally important for persons who are hypersensitive. Whenever these patients are out of doors, they should adhere to the following suggestions:
    • Avoid using perfumes or hygiene products that include perfumes as these may attract flying Hymenoptera.
    • Avoid wearing bright colors.
    • Avoid known hive or nest locations.
    • Do not use noisy equipment such as lawn mowers, edgers, or blowers within 50 yards of beehives or 150 yards of Africanized bee colonies.
    • Do not flail arms when confronted by bees or wasps because smashing one often incites others to sting.

Complications

  • Sting sites may become infected. Infection is more common in fire ant stings because they frequently are multiple; stings vesiculate and then ulcerate, leaving pruritic open wounds.
  • Rebound anaphylaxis may occur in patients with generalized reactions as antihistamine and alpha-agonist levels subside after treatment.
  • Anaphylaxis may occur in susceptible patients from exposure to other insect-related material, including honey and apiotherapy.
  • Serum-sickness-type reactions may occur up to 14 days after a sting.
  • Myocardial infarction, renal failure, DIC, and cerebral edema may occur after a bee sting.
    • One case report documents transient inferior ST-segment elevation consistent with myocardial ischemia after a single wasp sting in a 58-year-old man.3
    • In a retrospective analysis of medical records from 1985-2007, 7 of 45 pediatric patients were noted to have developed acute renal failure after a wasp sting.4
  • Peripheral nerve block may occur if sting is near the path of a nerve.

Prognosis

  • Most stings resolve with no residual complaints.
  • Large local reactions do not predispose patients to generalized reactions in the future.
  • Less severe generalized reactions precede most fatal reactions.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to remove stinger may produce infection or granulomatous reaction.
  • Failure to observe patient after treating a generalized reaction may result in unobserved rebound.
  • Failure to provide means of self-treatment in those with demonstrated tendency to generalized reactions may result in unnecessary future reactions. Refer these patients to an allergist for assessment.

Special Concerns

  • Infants are likely to sustain numerous fire ant stings, and they do not refrain from scratching open wounds, increasing the frequency of secondary infection. Some authorities recommend prophylactic antibiotics for children with more than 30 fire ant stings.
 


More on Hymenoptera Stings

Overview: Hymenoptera Stings
Differential Diagnoses & Workup: Hymenoptera Stings
Treatment & Medication: Hymenoptera Stings
Follow-up: Hymenoptera Stings
Multimedia: Hymenoptera Stings
References
Further Reading
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References

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Further Reading

Clinical guidelines

Stinging insect hypersensitivity: a practice parameter update. Moffitt JE, Golden DB, Reisman RE, Lee R, Nicklas R, Freeman T, deShazo R, Tracy J, Bernstein IL, Blessing-Moore J, Khan DA, Lang DM, Portnoy JM, Schuller DE, Spector SL, Tilles SA. Stinging insect hypersensitivity: a practice parameter update. J Allergy Clin Immunol 2004 Oct;114(4):869-86.

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Keywords

bee stings, yellow jacket sting, hornet sting, ant stings, wasp stings, vespid stings, bee envenomations, Hymenoptera envenomations, ant envenomations, wasp envenomations, vespid envenomations, Apis species, wasps, ants, severe anaphylactoid reactions, angioedema, respiratoryarrest, fatal allergic reactions, urticaria, confluent red rash

syncope, anxiety, confusion, wheezing, tachypnea, hypotension, laryngoedema, lingular edema, uvular edema, delirium, shock, honeybee stings, Africanized honeybee, , isoamylacetate, pheromone, apiotherapy, fire ants, , fire ant venom, Harvester ants, species

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Contributor Information and Disclosures

Author

Hemant H Vankawala, MD, Attending Physician, 24 Hour Emergency Room, Houston and Dallas; Attending Physician, Baylor University Medical Center; Medical Director, Big Bend National Park; Medical Director, Terlingua Fire and EMS; Medical Director, MedCare Ambulance Company
Hemant H Vankawala, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents Association, Society for Academic Emergency Medicine, and Texas Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Randy Park, MD, Chair, Associate Professor, Department of Emergency Medicine, Denton Regional Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Dan Danzl, MD, Chair, Department of Emergency Medicine, Professor, University of Louisville Hospital
Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

James Steven Walker, DO, MS, Clinical Professor of Surgery, Department of Surgery, University of Oklahoma Health Sciences Center
James Steven Walker, DO, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, and American Osteopathic Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Scott H Plantz, MD, FAAEM, Associate Clinical Professor of Emergency Medicine, Rosalind Franklin University of Medicine and Science, Chicago Medical School; Medical Director, WeCare Med, Inc
Scott H Plantz, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

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