Pediatric emergency medicine trisk 2010 2010
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The barbed honeybee stinger with venom sac is avulsed and often remains in
the victim’s skin. It must be removed if seen. Delays in removal are likely to
increase the dose of venom received. The method of removal of the stinger is
irrelevant (scraping vs. pulling vs. squeezing).
Management. Treatment of hymenoptera stings is based on the severity of the
allergic reaction. Local reactions can be treated with cold compresses at the site
of sting.
Group I reactions are treated with a second-generation antihistamine (loratidine
or cetirizine).
Group II and Group III reactions are treated with epinephrine 1:1,000 solution
0.01 mL/kg (maximum 0.5 mL) (or 0.01 mg/kg) IM followed by antihistamines
orally. Oral steroids (prednisone/prednisolone 2 mg/kg/day or dexamethasone)
are recommended. These children should be observed in the hospital for 24
hours.
Group IV reactions may require intubation if upper airway obstruction is
present. Hypotension should be treated with a fluid bolus of saline or lactated
Ringer solution 10 to 20 mL/kg given over 20 to 30 minutes. IV epinephrine
(1:10,000) should be considered if hypotension fails to respond to IM
epinephrine and fluid bolus. Hydrocortisone (2 mg/kg) may be given
intravenously for 4 days. All children in this group should be admitted to an
ICU.
Children who have had a group II, III, or IV reaction should be referred to an
allergist for desensitization. Parents of these children should keep an insect sting
emergency kit. The EpiPen and EpiPen Jr are spring-loaded autoinjectors
triggered by placing pressure on the thigh with the instrument. The pens inject 0.3
or 0.15 mg (EpiPen and EpiPen Jr, respectively) of epinephrine. The pens are
used as first aid in the field by the parent or guardian and are not meant to
substitute for prompt definitive treatment at a medical facility. Parents should
receive information regarding the use of epinephrine autoinjectors and avoidance
of situations and behaviors that would attract stinging insects. Children attending
summer camps should have an emergency dose of epinephrine with them.
Fire Ants. Current evidence. Fire ants (Solenopsis richteri and Solenopsis
invicta ) cause bites and envenomations in the South and increasingly in the
North. The venom is an alkaloid with a direct toxic effect on mast cell
membranes. There is no cross-reactivity with other members of the Hymenoptera
species.
