Hymenoptera Stings Follow-up

  • Author: Carrie de Moor, MD; Chief Editor: Scott H Plantz, MD, FAAEM   more...
 
Updated: Apr 26, 2010
 

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.
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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.
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Deterrence/Prevention

  • Avoiding stings is vitally important for persons who are hypersensitive. Whenever these patients are outdoors, 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.
  • Following severe reactions, individuals should be referred to an allergist/immunologist for potential immunotherapy and desensitization. Administration of venom-specific immunotherapy (VIT) is an established mode of treatment and offers long-term protection in 85-95% of cases.[2] New research on anti-immunoglobin (Ig) E antibody has shown promising results as a combination therapy for those unable to tolerate standard VIT.[2]
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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.[7]
    • 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.[8]
  • Peripheral nerve block may occur if sting is near the path of a nerve.
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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.
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Patient Education

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Contributor Information and Disclosures
Author

Carrie de Moor, MD  Adjunct Faculty, John Peter Smith Hospital, Emergency Medicine; Attending Physician, 24 Hour Emergency Room, Centennial Medical Center, Del Sol Emergency Department

Carrie de Moor, MD is a member of the following medical societies: American Medical Association and Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

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.

Randy Park, MD  Chair, Associate Professor, Department of Emergency Medicine, Denton Regional Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

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.

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.

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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Two fire ant stings that are 24 hours old (Randy Park, MD)
A paper wasp (Randy Park, MD)
A paper wasp (Randy Park, MD)
A paper wasp (Randy Park, MD)
 
 
 
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