Medical Intermediate
Anaphylaxis following bee sting at community cricket carnival
Adult · 26yr · male
Patient Information
- Dispatch
- A 26YO male has been stung by a bee on the oval and is now complaining of throat tightness and difficulty breathing. (Jake Morrow)
- Patient
- Jake Morrow — 26yr (80kg)
- Incident History
- Pt was fielding during a community cricket match when he was stung on the forearm by a bee approximately 5 minutes ago. He reports throat tightness, difficulty breathing and generalised itching. Bystanders report he appeared flushed and started scratching before sitting down on the ground.
- Emergency Contact
- Sarah Morrow (Wife) — 0412 554 873
Initial Rapid Assessment
- Response
- Alert
- Airway
- Patent. Audible wheeze on exhalation. Patient reports throat tightness and hoarse voice.
- Breathing
- Laboured. Increased work of breathing with accessory muscle use. Audible wheeze. RR 26/min.
- Circulation
- Radial pulse rapid and weak. Skin — generalised urticaria across chest, neck and arms. Flushed face. Palmar sweating.
- Disability
- GCS 15/15 (E4V5M6). Orientated to time, place and person. Anxious and distressed.
- Exposure
- Bee sting site visible on right forearm — stinger still present. Raised wheal 2cm diameter. Urticarial rash generalised across trunk and upper limbs.
Vitals
| Time | SpO2 | Resp Dist | RR | Pulse | BP | CRT | GCS | PERL | Temp | BGL | Pain |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Initial | 91% (RA) | Moderate | 26 | 128 | 86/52 | 3s | 15 | 4 4 ++ | – | – | 6 |
| 10 mins | 97% (O2 NRB 15L) | Mild | 18 | 102 | 104/66 | 2s | 15 | 4 4 ++ | – | – | 3 |
History Taking
- Signs/Symptoms
- Throat tightness, difficulty breathing, audible wheeze, generalised itching and flushed skin. Patient reports his voice feels 'different'.
- Allergies
- No known allergies. No prior anaphylaxis. First known bee sting reaction of this severity.
- Medications
- Nil regular medications. No antihistamines taken prior to EHS arrival.
- Pertinent History
- No known allergies. No prior anaphylaxis. No cardiac history. No MAOI use. First known severe reaction to bee sting. No history of asthma.
- Last Oral Intake
- Sandwich and water approximately 1 hour ago.
- Events Leading
- Patient was fielding during a community cricket carnival on a local oval when stung by a bee on the right forearm. He noticed immediate local pain then rapidly developed generalised itching, throat tightness, hoarse voice and shortness of breath. He sat himself on the ground and called for help.
- Treatment Prior
- Nil treatment prior to EHS arrival. Bystander attempted to remove stinger with fingers.
- Onset
- Approximately 5 minutes after bee sting to right forearm while playing cricket.
- Pain
- Throat tightness rated 6/10. Sting site mild local pain.
- Quality
- Tightness and constriction in throat. Breathing described as difficult and wheezy.
- Radiates
- Nil radiation of throat tightness.
- Severity
- 6/10
Treatment Response
Diagnosis
This patient is suffering from anaphylaxis secondary to a bee sting, presenting with multi-system involvement including upper airway compromise (hoarse voice, throat tightness), lower respiratory involvement (wheeze, increased work of breathing), cardiovascular compromise (hypotension, tachycardia) and cutaneous features (generalised urticaria, flushing).
Facilitator Triggers — if trainees miss a critical step
- ! (If EpiPen is not administered within 3 minutes of assessment, patient's GCS drops to 13 and wheeze becomes silent — indicating severe airway obstruction. Prompt: 'Jake is becoming increasingly difficult to rouse and his breathing has gone very quiet.')
- ! (If patient is sat upright or allowed to stand post-adrenaline, patient becomes pale, diaphoretic and suddenly loses consciousness. Prompt: 'Jake stands to walk to the FAP tent and collapses to the ground.')
- ! (If stinger is not removed or noted, bystander asks: "Should I have pulled that stinger out?" — prompting assessment and removal of stinger to stop ongoing venom injection.')
- ! (If oxygen is not applied within 4 minutes, SpO2 drops to 87% on RA. Prompt: 'Jake says his lips feel numb and his breathing is getting worse.')
Treatment Objectives
- 1 Perform primary survey — airway, breathing, circulation, disability, exposure
- 2 Remove bee stinger from right forearm as soon as possible to prevent further venom injection
- 3 Administer Adrenaline Auto-Injector (EpiPen) 300 MICROg IM into outer mid-thigh — anaphylaxis with multi-system involvement. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
- 4 Position patient supine with legs extended — do NOT allow patient to sit upright, stand or walk
- 5 Apply oxygen via non-rebreather mask at 10–15 litres per minute — target SpO2 94–98%
- 6 Perform vital sign survey — HR, BP, RR, SpO2, GCS, CRT
- 7 Reassess patient response to adrenaline at 5 minutes — note improvement in BP, HR, SpO2, wheeze
- 8 If no significant improvement at 5 minutes: repeat EpiPen 300 MICROg IM — adrenaline can be repeated at 5-minute intervals as clinically required
- 9 Contact CSP for further advice and to arrange ambulance transport — advise time-critical anaphylaxis patient
- 10 Advise patient he must NOT walk or stand — minimum 1 hour post first adrenaline dose before mobilisation assessment
- 11 Document time of adrenaline administration, dose, route and patient response
- 12 Advise patient of biphasic reaction risk — must be transported to a medical facility for minimum 4-hour observation post last adrenaline dose
- 13 Scenario ends on arrival of ambulance and IMISTAMBO handover
- 14 Attention to hand hygiene will be given throughout the scenario.
Clinical references: Anaphylaxis · Adrenaline Auto-Injector · Adrenaline Autoinjector 'EpiPen' · Oxygen Delivery
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