Scenario — Anaphylaxis following insect sting — 8-year-old male

intermediate Medical · Pediatric · 8yr · male

Patient Information

Dispatch	You are called to the FAP at the Perth Royal Show. A parent has brought in an 8-year-old boy who was stung by a bee near the animal exhibits approximately 5 minutes ago. The child is distressed and the parent states he is developing a rash.
Patient	Liam Nguyen — 8yr (26kg)
Incident History	Pt was walking past the livestock area when stung on the right forearm by a bee. Parent removed the stinger. Pt developed hives across the trunk and is now complaining of throat tightness and difficulty breathing.
Emergency Contact	Michelle Nguyen (Mother) — 0412 387 954

Initial Rapid Assessment

Response	Alert
Airway	Patent. Audible stridor noted. Mild swelling of lips. No visible foreign body.
Breathing	Increased work of breathing. Audible wheeze bilaterally. RR elevated. Using accessory muscles.
Circulation	Radial pulse rapid and weak. Skin: urticarial wheals across chest and abdomen, flushed face. CRT 3s.
Disability	GCS 14 (E4V4M6). Oriented to person and place. Agitated and tearful. Complaining of throat tightness.
Exposure	Raised urticarial wheals across trunk and upper arms. Bee sting site visible on right forearm — stinger already removed by parent. Lip swelling noted bilaterally.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	91% (RA)	Moderate	28	138	78/50	3s	14	4 4 ++	–	–	6
10 mins	97% (O2 NRB 10L)	Mild	20	108	92/60	2s	15	4 4 ++	–	–	3

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from anaphylaxis secondary to a bee sting, presenting with multi-system involvement including upper airway swelling (stridor, lip oedema, throat tightness), lower airway involvement (wheeze, increased work of breathing), cardiovascular compromise (hypotension, tachycardia, prolonged CRT), and cutaneous features (urticaria, flushing).

Facilitator Triggers — if trainees miss a critical step

! (If trainee does not administer adrenaline within 2 minutes of assessment: child's stridor becomes louder, SpO2 drops to 87% on RA, and child becomes more agitated and less responsive — GCS drops to 12. Facilitator states: 'Liam is getting worse, he's really struggling to breathe now.')
! (If trainee attempts to sit Liam upright or allows him to stand: facilitator states 'Liam suddenly looks very pale and limp — his mother catches him.' Patient becomes unresponsive. Vitals deteriorate: BP 60 systolic, GCS 9. Prompt trainee to position correctly immediately.)
! (If trainee fails to identify multi-system involvement and treats as mild allergic reaction only: facilitator states 'The rash is spreading and Liam is saying his throat feels worse.' Prompt identification of anaphylaxis criteria.)
! (If trainee does not apply oxygen following adrenaline administration: SpO2 remains at 91% at the 5-minute mark. Facilitator states: 'Mum asks why he still looks pale and is still breathing hard.')
! (If trainee does not request ambulance/higher care: prompt at 5 minutes — facilitator states 'Mum asks if Liam needs to go to hospital.' Trainees should escalate to Priority 1 transport with pre-notification.)

Treatment Objectives

1. Ensure scene safety and don appropriate PPE.
2. Perform primary survey — identify anaphylaxis based on multi-system involvement: airway swelling, wheeze, hypotension, and urticaria.
3. Position Liam supine with legs outstretched — do NOT allow to sit upright, stand or walk. Mother may stay with child for reassurance.
4. Administer Adrenaline Auto-Injector (EpiPen) 300 MICROg IM into outer mid-thigh — Liam weighs 26 kg, which exceeds the 20 kg threshold for EpiPen (adult 300 MICROg). Administer through a single layer of clothing if required.
5. Apply oxygen via non-rebreather mask at 10–15 L/min — titrate SpO2 to target 94–98%.
6. Conduct vital sign survey — assess RR, SpO2, HR, BP, CRT, and GCS.
7. Request ambulance backup immediately — Priority 1 transport with pre-notification of receiving facility. State: paediatric anaphylaxis, 8-year-old, adrenaline administered.
8. Continuously reassure Liam and his mother. Keep child calm and still.
9. Reassess vitals at 5 minutes — if no significant improvement in breathing, stridor, or haemodynamic status, prepare second EpiPen dose at 5-minute interval (300 MICROg IM).
10. Do NOT administer Loratadine — antihistamines have no role in treatment of anaphylaxis with respiratory or cardiovascular involvement.
11. Monitor Liam persistently — do not mobilise until minimum of 1 hour post single adrenaline dose, or 4 hours if more than one dose given.
12. Record full observations every 5 minutes given time-critical presentation.
13. Prepare for potential deterioration — ensure resuscitation equipment (BVM, AED) is immediately accessible.
14. Scenario ends on arrival of ambulance and IMISTAMBO handover.
15. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Anaphylaxis · Adrenaline Auto-Injector (EpiPen) · Oxygen · Primary Survey · Pulse Oximetry · Adrenaline Autoinjector 'EpiPen'

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Signs/Symptoms	Throat tightness, difficulty breathing, audible wheeze, lip swelling, widespread urticarial rash across trunk and arms, agitation.
Allergies	Mother unsure of any known allergies. No previous bee sting reactions. No EpiPen prescribed.
Medications	Nil regular medications.
Pertinent History	No known allergy history. No prior anaphylaxis. No cardiac or respiratory conditions. No medications.
Last Oral Intake	Ate a sausage sandwich approximately 30 minutes ago.
Events Leading	Child was walking with family near the livestock pavilion at the Perth Royal Show when stung by a bee on the right forearm.
Treatment Prior	Parent removed bee stinger immediately after sting. No medications given. Parent applied no other treatment.

Onset	Acute — approximately 5 minutes after bee sting to right forearm.
Pain	Throat tightness and difficulty breathing. Sting site sore. States throat feels like it is 'closing up'.
Quality	Constant and worsening since sting.
Radiates	Nil radiation of pain.
Severity	6/10 overall. Child very distressed.