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Hymenoptera Stings: Treatment & Medication
Updated: Apr 9, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
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:
- Diphenhydramine limits the size of the local reaction.
- Clean wound and remove stinger if present.
- Apply ice or cool packs.
- Elevate extremity to limit edema.
- Manage generalized reactions similarly to anaphylaxis, even in the absence of shock. 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.
Emergency Department Care
- Corticosteroids and cimetidine may be given IV; 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).
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.
Medication
Medications used to treat Hymenoptera stings include antihistamines (H1, H2), steroids, alpha- and beta-receptor agonists, and bronchodilators.
Antihistamines
These drugs directly block effects of some venom and effects of endogenously released histamine.
Diphenhydramine (Benadryl)
DOC for all stings, is an H1 and partial H2 receptor blocker used for symptomatic relief of allergic symptoms caused by histamine released in response to allergens.
Adult
50-75 mg PO/IM q4h; IV may be administered slowly in emergency situations
Pediatric
1-2 mg/kg PO/IM
Potentiates effect of CNS depressants; due to alcohol content, do not give syrup dosage form to patient taking medications that can cause disulfiramlike reactions
Documented hypersensitivity; MAOIs
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction
Cimetidine (Tagamet)
Indicated for systemic reaction that does not respond completely to diphenhydramine, or when severity indicates need for maximal treatment.
Adult
300-800 mg IV q6h
Pediatric
5 mg/kg IV q6h
Can increase blood levels of theophylline, warfarin, tricyclic antidepressants, triamterene, phenytoin, quinidine, propranolol, metronidazole, procainamide, and lidocaine
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Older patients may experience confusional states; may cause impotence and gynecomastia in young males due to weak antiandrogen properties; may increase levels of many drugs; consider adjusting dosage or discontinuing treatment if renal function changes occur during therapy
Bronchodilators
Epinephrine causes vasoconstriction, bronchodilation, and increased cardiac output. The effects of albuterol and theophylline are more focused on bronchodilation.
Epinephrine (Epi-Pen)
DOC for systemic reactions, has alpha-agonist effects that increase peripheral vascular resistance and reverse peripheral vasodilation, systemic hypotension, and vascular permeability. Conversely, beta-agonist activity of epinephrine produces bronchodilation, chronotropic cardiac activity, and positive inotropic effects. Epinephrine may be self-administered through auto-injectors.
Adult
0.2-1 mg IV/SC
Pediatric
0.01-0.1 mg/kg IV/SC
Increases the toxicity of beta- and alpha-blocking agents and of halogenated inhalational anesthetics
Documented hypersensitivity; cardiac arrhythmias; angle-closure glaucoma; avoid coadministration with local anesthesia in areas such as fingers or toes because vasoconstriction may produce sloughing of the tissue; do not use during labor as it may delay the second stage of labor
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in older persons and in patients with diabetes mellitus, hyperthyroidism, prostatic hypertrophy, hypertension, cardiovascular disease, and cerebrovascular insufficiency; rapid IV infusions may cause death from cerebrovascular hemorrhage or cardiac arrhythmias
Albuterol (Proventil, Ventolin)
Adjunctive treatment for bronchospasm given by nebulization, it is a beta-agonist useful to treat bronchospasm refractory to epinephrine. Relaxes bronchial smooth muscle by action on beta2-receptors and has little effect on cardiac muscle contractility.
Adult
2.5 mg by nebulization in 3 cc saline
May be repeated q15min or administered continuously in severe cases
Pediatric
0.1 mg/kg by nebulization in 3 mL saline, not to exceed 2.5 mg
May be repeated q15min or administered continuously in severe cases
Beta-adrenergic blockers antagonize effects; inhaled ipratropium may increase duration of bronchodilatation by albuterol; cardiovascular effects may increase with MAOIs, inhaled anesthetics, tricyclic antidepressants, and sympathomimetic agents
Documented hypersensitivity; adrenergic amines, or related products; history of tachycardia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperthyroidism, diabetes mellitus, and cardiovascular disorders
Theophylline (Aminophylline)
Used to relieve bronchospasm in resistant cases, acts to decrease muscle tone in both small and large airways in lungs, thus increasing ventilation.
Efficacy managing bronchodilation may be due to its potentiation of exogenous catecholamines, stimulation of endogenous catecholamine release, and diaphragmatic muscular relaxation. Effects as a bronchodilator usually are seen at levels considered to be toxic (>20 mg/dL).
Adult
Loading dose: 5-6 mg/kg IV over 30 min, then 0.9 mg/h
Adjust rate as tolerated to achieve therapeutic levels of 10-20 mcg/mL
Pediatric
Administer as in adults
Aminoglutethimide, barbiturates, carbamazepine, ketoconazole, loop diuretics, charcoal, hydantoins, phenobarbital, phenytoin, rifampin, isoniazid, and sympathomimetics may decrease effects of theophylline; theophylline effects may increase with allopurinol, beta-blockers, ciprofloxacin, corticosteroids, disulfiram, quinolones, thyroid hormones, ephedrine, carbamazepine, cimetidine, erythromycin, macrolides, propranolol, and interferon
Documented hypersensitivity; uncontrolled arrhythmias, peptic ulcers, hyperthyroidism, uncontrolled seizure disorders
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in peptic ulcer, hypertension, tachyarrhythmias, hyperthyroidism, and compromised cardiac function; do not inject IV solution faster than 25 mg/min; patients diagnosed with pulmonary edema or liver dysfunction are at increased risk of toxicity because of reduced drug clearance
Corticosteroids
These drugs act to stabilize lymphocytes and to reduce release of endogenous vasoactive compounds.
Methylprednisolone (Solu-Medrol, Depo-Medrol)
Indicated in all cases of generalized reaction unless contraindications exist. Useful to treat inflammatory and allergic reactions. May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
Adult
0.25-1 g IV over 30 min q6h
Pediatric
0.2-2 mg/kg IV over 30 min q6h
Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phenobarbital, phenytoin and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use
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 |
| « Previous Page | Next Page » |
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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.
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
