Anaphylactic Shock from Bee Sting Treatment

Immediate Actions

The American Heart Association recommends immediately administering intramuscular epinephrine 0.3-0.5 mg in adults (0.01 mg/kg up to 0.3 mg in children) into the anterolateral thigh and activating emergency medical services, as this is the single most critical intervention that saves lives 1, 2
Remove the stinger immediately by scraping or flicking it away with a fingernail to prevent additional venom injection 1, 2
Administer epinephrine via intramuscular injection in the anterolateral thigh, as this route achieves faster and higher plasma concentrations, with an adult dose of 0.3-0.5 mg and a pediatric dose of 0.01 mg/kg (maximum 0.3 mg) 2
Call emergency services immediately after administering epinephrine, without delay 1, 3
Position the patient supine with legs elevated if hypotension develops, to prevent sudden death from "empty-ventricle syndrome" 4, 3

Be prepared to repeat epinephrine every 5 minutes if symptoms persist or worsen, as delayed or inadequate epinephrine use is associated with fatal outcomes 5, 2, 3
For refractory hypotension despite multiple IM doses, transition to intravenous epinephrine infusion, with a dose of 1 mg epinephrine in 250 mL D5W, infused at 1-4 mcg/min, titrating up to 10 mcg/min in adults 5
Administer 1-2 liters of IV normal saline bolus for persistent hypotension, as massive fluid shifts occur during anaphylaxis 5

Administer supplemental oxygen to all patients with prolonged reactions, hypoxemia, or requiring multiple epinephrine doses 5
Give inhaled albuterol (2.5 mg nebulized) for bronchospasm that persists despite epinephrine 5
Administer H1 antihistamines (diphenhydramine 25-50 mg IV/IM in adults) and H2 blockers (ranitidine 50 mg IV or famotidine 20 mg IV) as adjuncts, but these do not treat life-threatening symptoms 5
Give corticosteroids (methylprednisolone 125 mg IV or prednisone 0.5 mg/kg PO) to potentially prevent biphasic reactions, though they have no immediate effect 5, 2

Never delay epinephrine administration, as antihistamines and corticosteroids are not substitutes and delayed epinephrine is associated with fatal outcomes 2
Do not assume the reaction is over after initial improvement, as biphasic reactions can occur hours later 2
Do not use subcutaneous epinephrine or inject in the arm, as intramuscular injection in the thigh is superior 2, 3
Avoid raising the patient to upright position during shock, and maintain supine position with legs elevated 4

Eye stings require immediate ophthalmology evaluation, as they can cause permanent vision loss 1, 3
Multiple stings (>100) can cause toxic reactions from massive envenomation that mimic anaphylaxis but result from direct venom effects rather than allergic mechanisms 2, 3
Patients on beta-blockers may be refractory to epinephrine and require higher doses or alternative vasopressors like glucagon 4
There are no contraindications to epinephrine in anaphylaxis, even in patients with cardiovascular disease, as the benefits far outweigh risks 2

Prescribe epinephrine autoinjector (EpiPen or equivalent) before discharge and demonstrate proper use 4, 2, 3
Refer all patients to an allergist-immunologist for venom-specific IgE testing and consideration of venom immunotherapy, which dramatically reduces risk of future anaphylaxis 2, 3
Educate on trigger avoidance, including avoiding walking barefoot outdoors, wearing protective clothing, avoiding bright colors and floral patterns, eliminating scented products, and having nests professionally removed 3