Emergency Department Management of Bee Sting to the Back of Throat

Initial Assessment and Management

• Remove the stinger as quickly as possible if visible, using tweezers or by scraping, as venom can continue to be delivered for up to 60 seconds, according to the American Heart Association 1, 2

Pharmacological Management

• Administer epinephrine 0.01 mg/kg (up to 0.3 mg) in children and 0.3-0.5 mg in adults via intramuscular injection in the anterolateral thigh, as recommended by the American Academy of Allergy, Asthma, and Immunology 3

Monitoring and Observation

• Be prepared for rapid deterioration, as laryngeal edema is the most common cause of death from Hymenoptera-induced anaphylaxis, with a high level of evidence from the Journal of Allergy and Clinical Immunology 4

Discharge Planning

• Prescribe epinephrine auto-injector for all patients with history of systemic reaction to insect sting, as recommended by the American Academy of Allergy, Asthma, and Immunology 5, 3
• Consider referral to an allergist-immunologist for venom-specific IgE testing and possible venom immunotherapy, with moderate evidence from the Journal of Allergy and Clinical Immunology 5, 6

Special Considerations

• Multiple stings increase risk of toxic reactions due to massive envenomation, according to the American Heart Association 1, 3
• Venom immunotherapy should be considered for patients with history of systemic reactions to reduce risk of future anaphylaxis, with strong evidence from the Journal of Allergy and Clinical Immunology 6

Pitfalls to Avoid

• Failing to remove the stinger promptly can result in continued envenomation, as warned by the American Heart Association 1, 2
• Mistaking swelling for infection and inappropriately prescribing antibiotics instead of focusing on anti-inflammatory treatment, with moderate evidence from the Journal of Allergy and Clinical Immunology 7