Hymenoptera Stings Treatment & Management

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

Prehospital Care

Prehospital care must assess severity immediately and provide immediate appropriate treatment, because the most endangered patients die within 30 minutes of a sting.

Local reactions can be life threatening if swelling occludes the airway. Initiate invasive measures to secure the airway if this occurs. Otherwise, the following local care measures suffice.

  • Provide supplemental oxygen
  • Diphenhydramine limits the size of the local reaction.
  • Clean the wound and remove the stinger if present.
  • Apply ice or cool packs.
  • Elevate the extremity to limit edema.

Manage generalized reactions similarly to anaphylaxis, even in the absence of shock. Increased vascular permeability in anaphylaxis may result in transfer of 50% of the intravascular fluid into the extravascular space within 10 minutes.[1] Check airway and ventilatory status. Treatment should include an initial intravenous (IV) bolus of 10-20 mL/kg isotonic crystalloids in addition to diphenhydramine and epinephrine.

If the patient has not removed the stinger, it should be removed as soon as possible by the first caregiver on the scene. Delay increases venom load, so the fastest removal technique is the best. Pinching and traction is an acceptable technique.

EMT or self-administration of intramuscular or subcutaneous epinephrine should be initiated immediately in the event of severe reaction. Intramuscular epinephrine injections into the lateral thigh provide more rapid absorption and higher plasma epinephrine levels than intramuscular or subcutaneous injections administered in the arm.[1]

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Emergency Department Care

  • Corticosteroids should be administered in severe cases to prevent recurrent or prolonged anaphylaxis, although acutely, they are not likely to improve symptoms.
  • H2 blockers such as ranitidine and cimetidine may be given intravenously. Administration of one of these medications combined with diphenhydramine is superior to diphenhydramine alone.[1]
  • In cases of refractory anaphylaxis, glucagon may be helpful if concomitant beta-blockers are preventing adequate response to epinephrine treatment.[1]
  • Vasopressors such as dopamine can be used to provide vascular support.
  • Patients developing respiratory arrest require ventilatory support.
  • Blood products may be required in the event of disseminated intravascular coagulation (DIC).
  • Repeated doses of epinephrine may be indicated for severe cases.
  • In the event of cardiopulmonary arrest due to anaphylaxis, intravenous epinephrine should be administered as a first-line agent.[1]
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Consultations

  • Refer all patients with generalized reactions to an allergist as soon as possible, because risk of fatal reaction is inversely related to length of time since the last sting.
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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)
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A paper wasp (Randy Park, MD)
A paper wasp (Randy Park, MD)
 
 
 
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