This issue includes 4 hours of ACEP/AMA category 1 CME credit.
Authors: Sing-Yi Feng, MD and Collin Goto, MD
Peer Reviewers: George Hutchinson, MD, FAAEM and Joseph Toscano, MD
Publication Date: June 1, 2008
Excerpt from the issue… Imagine these scenarios:
Paramedics call your emergency department to inform you that they are transporting a 12-year-old boy who was stung several hundred times by a swarm of honeybees. The patient is agitated and has innumerable erythematous papular stings to his face and extremities. What are your immediate priorities, and what are your subsequent concerns for delayed toxicity?
A 7-year-old girl is brought to triage by her parents after she was stung a single time by a wasp. She is lethargic with facial swelling and a generalized urticarial rash. In addition, she has respiratory distress with bilateral wheezes on lung examination, and pulse oximetry demonstrates oxygen saturations of 87% on room air. How should this life-threatening situation be managed?
A 2-year-old male is transported to your emergency department after stumbling into a fire ant nest. He is crying, irritable, and tachycardic but has no respiratory distress. He has multiple erythematous papules on his legs that are beginning to form fluid-filled vesicles. What is the treatment for this envenomation?
Conclusion to the above case study... This 12-year-old boy sustained massive bee envenomation, likely the result of an aggressive swarm of Africanized honeybees. You observed that he had several hundred bee stings to his face, extremities, and torso, but no evidence of anaphylaxis. The immediate priorities of airway, breathing, and circulation were attended to. He was breathing comfortably without stridor, wheezes, or hypoxia. He had moderate tachycardia but no hypotension. Intravenous access was obtained, and the patient was treated with intravenous fluids, corticosteroids, antihistamines, and analgesia. Although he remained stable for several hours in the emergency department, you admitted him for observation due to your concerns that he may develop delayed toxicity secondary to the massive envenomation. In the hospital, the patient did indeed decompensate 12 hours after admission with vomiting, tachycardia, hypotension, and altered mental status. Laboratory evaluation revealed hemolysis, hemoglobinuria, rhabdomyolysis, renal insufficiency, and hepatic transaminase enzyme elevations. Aggressive supportive care measures in the intensive care unit were required to stabilize the patient. His condition gradually improved, and he was discharged home in good condition after 1 week in the hospital.
You immediately recognized that this 7-year-old girl was experiencing an anaphylactic reaction to the wasp sting and brought her to the resuscitation room for aggressive management of this life-threatening emergency. Oxygen and nebulized albuterol were administered, and the patient was given an intramuscular injection of epinephrine simultaneously. Intravenous access was obtained, and the patient received fluids, antihistamines, and corticosteroids. Her initial blood pressure was 72/40 mm Hg, and this improved to 90/64 mm Hg after 1 dose of epinephrine and 2 boluses of normal saline. Her wheezing and oxygen requirement resolved, and her mental status improved. She continued to have generalized urticaria, but the rash had faded considerably. You breathed a sigh of relief as you consulted the allergy-immunologist and made arrangements for hospital admission.
Your initial examination of the child revealed no respiratory distress or other signs of anaphylaxis, and the parents were not aware of the child having any prior exposure to fire ants. After confirming that the child had no significant compromise of vital signs, you felt comfortable that the child’s envenomation could be treated with good wound management and symptomatic care. The affected areas were gently cleansed with soap and water, and cool compresses were applied. The child’s tetanus status was confirmed to be current. The patient’s pain and itching were treated with oral ibuprofen and diphenhydramine. His irritability and tachycardia resolved as he stopped crying and became more comfortable. Prior to discharge home, you reassured the parents, who were thankful for the good care their child received.
About this article: This issue of Pediatric Emergency Medicine Practice will focus on the evaluation and management of the child with Hymenoptera envenomation.
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