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IM21.9 | Bee Sting and Other Envenomation — SDL Guide (Part 2)

Management Principles: Stabilisation and Specific Treatments

Across all envenomation types covered in this module, three management principles apply universally and form a mental framework for the first minutes of any encounter. First, identify the mechanism — IgE-mediated anaphylaxis requires adrenaline IM as the only life-saving first-line treatment, while direct toxic envenomation (massive stings, haemolysis, organ injury) requires supportive intensive care and aggressive fluid replacement. Second, remove the source — extract bee stingers by scraping (not pinching), pick off jellyfish tentacles without rubbing, leave snake fangs/stingers if embedded deeply and plan surgical removal under anaesthesia if needed. Third, treat the complication, not just the acute event — monitor for AKI in massive envenomation, biphasic anaphylaxis in single sting cases, and late serum sickness in antivenom recipients. Applying these three principles within the first five minutes converts a chaotic emergency encounter into a structured management sequence.

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For anaphylaxis from any cause (bee, wasp, jellyfish, antivenom): adrenaline 0.5 mg IM anterolateral thigh → IV access + fluids → adjuncts (chlorphenamine 10 mg IV, hydrocortisone 200 mg IV) → salbutamol nebulisation for bronchospasm → observe 4–6 hours for biphasic reaction.

For massive envenomation with organ toxicity (>50–100 bee stings, any species): IV fluids 200–300 mL/hour targeting UO ≥200 mL/hour → serial creatinine, CK, urine dipstick → ICU admission → dialysis if AKI progresses.

For jellyfish: do not rub → seawater flush → vinegar 30 min → analgesia.

For centipede: analgesia (oral or local lignocaine) + ice + tetanus toxoid + 6 hours observation.

For black widow spider (latrodectism): opioid analgesia (morphine 5–10 mg IV titrated) + benzodiazepine (diazepam 5–10 mg IV) for muscle rigidity + antihypertensive for severe hypertension + antivenom where available.

Self-Assessment: Integrated Envenomation Management

The self-assessment scenarios below consolidate the key diagnostic and management principles across the spectrum of envenomation covered by IM21.9. The unifying clinical skill is rapid syndrome recognition — identifying within the first two minutes of assessment whether the patient has anaphylaxis (single sting, sensitised, requires adrenaline immediately), direct toxic envenomation (massive stings, unsensitised, requires supportive care and aggressive fluids), or a specific arthropod presentation (jellyfish requiring vinegar, centipede requiring analgesia, black widow requiring muscle relaxants). The scenarios below are designed to train this rapid pattern-recognition across the range of common presentations that an Indian physician in any practice setting may encounter. Work through each scenario independently before reading the analysis. The key differentiating questions are always the same: Was this one sting or many? Is there urticaria and wheeze (anaphylaxis) or dark urine and rising creatinine (toxic)? What did the creature look like and what environment did the patient come from? Systematic application of these three questions within the first two minutes of any envenomation encounter will direct you to the correct treatment before investigation results are available.

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Scenario A: A 45-year-old beekeeper is brought in after being stung approximately 300 times when a swarm attacked him. He has no history of allergy. He is conscious but distressed, has diffuse oedema, and his urine is dark red-brown. Serum creatinine is 2.8 mg/dL on admission. There is no urticaria or wheeze. What is the primary threat and immediate management priority?

Analysis: Massive toxic envenomation — NOT anaphylaxis (no urticaria, no wheeze, no history of allergy). Primary threat: pigment nephropathy (haemoglobinuria + myoglobinuria) leading to AKI. Immediate priority: aggressive IV fluid hydration (normal saline at 200–300 mL/hour) to achieve urine output ≥200 mL/hour and flush pigment casts. Serial creatinine, urine dipstick, CK, LDH monitoring. ICU admission. No role for adrenaline — this is direct toxicity, not anaphylaxis.

Scenario B: A 28-year-old tourist in Goa develops immediate burning pain and linear erythematous tracks on the thigh after swimming. She comes to the beach clinic in distress. The marks are branching and there are gelatinous fragments attached to the skin. What is the correct sequence of first aid?

Analysis: Jellyfish envenomation. Correct sequence: (1) do NOT rub; (2) pick off gelatinous tentacle fragments with a card-edge or tweezers; (3) flush with seawater (NOT fresh water); (4) apply 5% vinegar for 30 minutes; (5) analgesia (paracetamol or tramadol); (6) observe for systemic features. If anaphylaxis develops (urticaria, hypotension): adrenaline 0.5 mg IM.