Anaphylaxis following insect sting — paediatric female

Patient Information

Dispatch: You are called to a patient (Lily Nguyen, 8-year-old female) who has been stung by a bee at the school carnival and is now having difficulty breathing with a rash spreading across her body.
Patient: Lily Nguyen — 8yr (25kg)
Incident History: Pt stung by bee on left forearm approximately 5 minutes ago. Parents removed the sting. Pt developed hives on arms and face, began complaining of throat tightness and is now wheezing.
Emergency Contact: Minh Nguyen (Father) — 0412 883 247

Initial Rapid Assessment

Response: Alert
Airway: Patent but patient reports throat feels 'tight'. No stridor audible at this time. Mild lip swelling noted.
Breathing: Audible wheeze on expiration. Increased work of breathing with accessory muscle use. RR elevated.
Circulation: Radial pulse rapid and weak. Skin flushed with raised urticarial wheals spreading across both forearms and face. Pale around mouth.
Disability: GCS 15 (E4V5M6). Alert and distressed. Orientated to time, place and person.
Exposure: Urticarial wheals on bilateral forearms and face. Bee sting site visible on left forearm — sting removed by parent. No other injuries noted.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	92% (RA)	Moderate	28	128	88/60	3s	15	4 4 ++	–	–	6
10 mins	98% (O2 NRB 10L)	Mild	20	104	102/68	2s	15	4 4 ++	–	–	3

History Taking

Treatment Response

Diagnosis

This patient is suffering from anaphylaxis secondary to a bee sting, presenting with multi-system involvement including urticaria, angioedema, bronchospasm, and haemodynamic compromise.

Facilitator Triggers — if trainees miss a critical step

! (If trainee does not identify anaphylaxis and attempts to treat as localised allergic reaction only — Lily's wheeze becomes louder and she begins to drool. Father says 'she looks worse, please do something'.)
! (If EpiPen is not administered within 3 minutes of patient contact — Lily's GCS drops to 13, she becomes more drowsy and her SpO2 drops to 88% on room air.)
! (If trainee attempts to sit Lily upright in a chair — father assists her to stand. Prompt trainee: Lily becomes pale and nearly faints. She must be positioned supine or semi-recumbent with legs outstretched.)
! (If oxygen is not applied — SpO2 remains at 92% or drops. Prompt: Lily's lips are turning slightly blue.)
! (If trainee does not reassess BP after EpiPen — Lily remains tachycardic and pale. Prompt: 'Is Lily improving?')

Treatment Objectives

1 Ensure scene safety — school carnival environment, confirm no further bee/insect threat in the immediate area.
2 Don appropriate PPE.
3 Perform Primary Survey — confirm patent but threatened airway (lip swelling, throat tightness), moderate respiratory distress with wheeze, weak rapid radial pulse, urticarial rash across two or more body systems.
4 Identify anaphylaxis — multi-system involvement (skin + respiratory + cardiovascular) following bee sting trigger.
5 Position Lily supine with legs outstretched — do NOT allow her to sit upright in a chair or stand. Semi-recumbent acceptable only if respiratory distress demands it.
6 Remove trigger — confirm bee sting removed by parent (already done). Check no stinger fragments remain in left forearm.
7 Administer Adrenaline Auto-Injector (EpiPen) 300 MICROg IM to outer mid-thigh — Lily weighs 25 kg, which is over 20 kg, therefore EpiPen (adult 300 MICROg) is indicated, NOT EpiPen Jr. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
8 Administer oxygen via non-rebreather mask at 10–15 L/min — titrate to target SpO2 94–98%. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
9 Perform Vital Signs Survey — RR, SpO2, BP, HR, CRT, GCS.
10 Record full observations and pain score.
11 Reassess clinical response at 5 minutes post EpiPen — if no significant improvement, prepare second EpiPen for repeat dose at 5-minute interval as clinically required.
12 Monitor persistently — do NOT mobilise Lily for a minimum of 1 hour following one dose of adrenaline.
13 Contact CSP for further advice and to arrange ambulance transport — advise of paediatric anaphylaxis, EpiPen administered, current observations.
14 Advise father: Lily must be transported to hospital for monitoring for minimum 4 hours after last adrenaline dose due to risk of bi-phasic reaction.
15 Scenario ends on arrival of ambulance and IMISTAMBO handover.
16 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Anaphylaxis · Adrenaline Autoinjector 'EpiPen' · Oxygen Delivery · Primary Survey · Pulse Oximetry · Blood Pressure · Pulse & Respirations

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