TheJournalof EmergencyMedicine,Vol 13,No 1,pp 9-13, 1995
Pergamon
Original
Contributions
MANAGEMENT OF HYMENOPTERA STING ANAPHYLAXIS:
A PREVENTIVE MEDICINE SURVEY
Leon McDougle, MD,*
*Family Practice Department, Naval Hospital,
tSan Diego Clinical Research
Reprint Address: Lt. Leon McDougle, MC, USNR, c/o Clinical Investigation
0 Abstract -The evaluation of aftercare instructions
given to patients suffering from hymenoptera sting ana-
phylaxis was the objective of the study. Part of this evalua-
tion included asking the physicians questions to examine
the knowledge on which they based their aftercare instruc-
tions. Survey questionnaires were completed by 124 of 174
(71% ) physicians who worked in an emergency department
or urgent care center. Fifty-eight percent of the physicians
never provided written avoidance instructions, 24% pro-
vided or prescribed anaphylaxis ID bracelets, 44% referred
all of their patients to an allergist for further evaluation,
and 73% reported prescribing an Epi-pen or Ana-kit to all
hymenoptera sting anaphylaxis victims. Twenty-four per-
cent of physicians did not know where to obtain anaphy-
laxis identification bracelets. This survey demonstrates that
a substantial number of physicians practicing emergency
medicine are not providing appropriate aftercare instruc-
tions to patients, and substantiates the need for educational
efforts to increase the awareness of physicians concerning
the implications of hymenoptera allergy and the value of
proper preventive measures.
0 Keywords - hymenoptera; anaphylaxis; preventive
medicine
The Chief, Navy Bureau of Medicine and Surgery, Wash-
ington, DC, Clinical Investigation Program sponsored
this study 84-16-1968-377, as required by HSETCINST
6000.41. The views expressed in this article are those of the
authors and do not reflect the official policy or position of
the Department of the Navy, Department of Defense, nor
the United States Government.
RECEIVED: 22 October 1993; FINAL SUBMISSION RECEIVED: 28 February 1994;
ACCEPTED: 21 March 1994
1995ElsevierScienceLtd
Printedin theUSA. All rights reserved
0736-4679/95$9.50 + 30
Gerald L. Klein, MD,t and Fred K. Hoehler, Ptmt
CampPendleton, California, and Clinical Investigation Department, Naval Hospital,
San Diego, California;
Associates, Carlsbad, California
Department, Naval Hospital, San Diego, CA 921345000
INTRODUCTION
Hieroglyphic writings on the tomb of King Menes of
Egypt record the first documented death caused by a
hornet or wasp (hymenoptera) in 2621 BC ( 1). The
order of hymenoptera includes bumblebees, honey
bees, yellow jackets, white faced hornets, yellow
faced hornets, wasps, and fire ants.
The preventive medicine aspects of treating hyme-
noptera sting anaphylaxis are important but are often
overlooked in the acute care setting. Allergic reac-
tions to insect stings are reported by approximately
0.4% of the population in the United States (2,3).
Nearly 40 deaths per year are attributed to systemic
reactions caused by hymenoptera sting venom (4).
However, it is believed that the actual number is
higher because an unknown number of deaths due to
hymenoptera anaphylaxis are mistakenly attributed
to sudden cardiovascular events.
In 1989, Hutcheson and Slavin (5) retrospectively
interviewed 76 patients who had received emergency
department treatment for hymenoptera sting anaphy-
laxis. They found that 18% of patients received written
avoidance instructions, 29% were given an Epi-pen or
Ana-kit for initial self-treatment, and 56% were re-
ferred to an allergist for desensitization therapy. No
specific information was provided about the location
or types of institutions in which the patients received
treatment, and the physicians were not questioned about
their knowledge of preventive medicine practices.
9
Table 1. Survey Questions 81Answers

Instructions: The questions below (1-Q) are concerned with the management of hymenoptera sting anaphylaxis in the adult patient.
(Injectable epinephrine in the following questions refer to predosed epi-pen or ana-kit preparations.)
1. Is the role of the emergency department to provide or prescribe anaphylaxis identification bracelets?
N %
- -
a. yes 47 38.84
b. no 74 81.18
2. Approximately, what percentage of patients with systemic anaphylactic reactions (i.e. bronchospasm, urticaria, hypotension) did you
provide or prescribe anaphylaxis identification bracelets?
N %
- -
a. 100% 12 10.17
b. 50% 8 8.78
c. 25% 8 5.08
d. 10% 2 1.89
e. 0% 82 52.54
f. Did not know where patient could obtain ID bracelet 28 23.72
3. Choose the type of anaphylactic reaction(s) that do NOT require referral to allergist for skin testing and possible desensitization
immunotherapy:
N %
--
a. Hiveslurticaria 38 23.75
b. Angioedema 8 3.75
c. Large local reaction 74 48.25
d. Hypotension 4 2.50
e. Bronchospasm 1 0.83
f. All of the above require referral 37 23.13
4. Approximately what percentage of all insect sting anaphylaxis patients did you refer to allergist for skin testing and possible
desensitization immunotherapy?
N %
- -
a. 100% 47 38.21
b. 50% 14 11.29
c. 25% 9 7.32
d. 10% 17 13.82
e. 0% 19 15.45
f. Never treated patient with insect sting anaphylaxis 17 13.82
5. If a patient’s anaphylactic reaction after hymenoptera insect sting consists of mild, local edema at the bite and generalized urticaria,
is it appropriate to prescribe injectable epinephrine for initial outpatient self treatment?
N %
- -
a. yes 79 64.23
b. no 44 35.77
6. Approximately what percentage of patients with a history of systemic reaction such as bronchospasm, hypotension, or urticaria did
you prescribe epinephrine for future initial outpatient self-treatment?
N %
--
a. 100% 77 63.11
b. 50% 7 5.74
c. 25% 1 0.82
d. 10% 7 5.74
8. 0% 13 10.66
f. Never treated patient with insect sting anaphlaxis 17 13.93
7. After self-treatment of hymenoptera sting with injectable epinephrine, should the patient:
N %
- -
a. Visit nearest ED immediately 107 84.92
b. Do not visit ED if initial improvement noted 1 0.79
c. Call his/her primary care physician 18 14.29
8. Approximately what percentage of patients with insect sting anaphylaxis have you provided written information on how to avoid
insect stings?
N %
- -
a. 100% 23 19.01
b. 50% 7 5.79
c. 25% 5 4.13
d. 10% 9 7.44
8. 0% 60 49.59
f. never treated patient with insect sting.anaphylaxis 17 14.05
Hymenoptera Sting Anaphylaxis 11

Table 2. Selected Responses From Physic&o Who Treated noptera sting anaphylaxis within the previous 12-
Hymenoptera Sting Anaphylaxis Patients in the
Previous 12 Months month period.

Percentage of patients with insect anaphylaxis who were re-

ferred to an allergist (Question 4)
MATERIALS AND METHODS
% of Patients N O/O of Respondents

100% 47 44.34 A survey questionnaire was mailed to 174 physicians.

50% 14 13.21 One-half of each group, the odd-numbered urgent
25% 9 a.49
10% 17 16.04 care centers and emergency departments, were cho-
0% 19 17.92 sen to participate in the survey. The survey included
physicians from 64 of 127 U.S. medical schools, 62
Percentage of patients with a history of systemic reaction for
whom epinephrine was prescribed for self-treatment (Question 6) of 124 continental U.S. military hospitals, 33 of 65
California urgent care centers, and 15 of 30 Kaiser
% of Patients N % of Respondents
Permanente HMOs. The names of the urgent care
100% 77 73.33 center physicians were obtained through a list pro-
50% 7 6.67
25% 1 0.95 vided by the National Association of Ambulatory
10% 7 6.67 Care. The other physicians were identified by tele-
0% 13 12.36 phoning emergency departments, as listed by the
American Hospital Association (6).
Percentage of patients with insect sting anaphyfaxis to whom
written avoidance instructions were given (Question 8) The total design method, as proposed by Dillman,
O/oof Patients N % of Respondents was utilized during the survey to optimize the ques-
tionnaire completion rate (7). First, a cover letter
100% 23 22.12 and questionnaire were mailed out on a Monday by
50% 7 6.73
25% 5 4.81 first class mail. Exactly 1 week later, a postcard fol-
10% 9 8.65 low-up was sent to all recipients of the first mailing.
0% 60 57.69 A second follow-up was mailed to nonrespondents
Data for the 17 physicians who did not treat such patients are exactly 3 weeks after the original mailout, which con-
excluded. sisted of a cover letter informing the physicians that
their response had not been received, a restatement
of the original basic appeal, and a replacement ques-
This survey utilizes a nation-wide sample of physi- tionnaire return envelope. The third and final fol-
cians who work in an emergency department in either low-up was sent via certified mail 7 weeks after the
a military hospital, a medical school hospital, or a original mailing, consisting of a cover letter and an-
health maintenance organization (HMO). Physicians other questionnaire and return envelope.
practicing in urgent care centers were also surveyed.
The evaluation of aftercare instructions given to pa- RESULTS
tients suffering from hymenoptera sting anaphylaxis
was the objective of the study. Part of this evaluation A rate of 124 of 174 (71%) completed responses
included asking the physicians questions to examine were obtained from the survey. The physician re-
the knowledge on which they based their aftercare sponse rate from HMOs, urgent care centers, medical
instructions. The physicians were also asked about school hospitals, and military hospitals equaled 93 Vo,
the number of patients they had treated for hyme- 59%, 67%, and 83%, respectively. Physicians from
37 different states participated in the survey. Sev-
enty-seven percent of the physicians reported treating
Table 3. Number of Patients Treated During the Previous at least one hymenoptera sting anaphylaxis patient
12 Months
during the prior 1Zmonth period. The questionnaire
Site Mean Median SD Range results are listed in Tables l-3. Table 2 excludes the
17 physicians who had never treated hymenoptera
HMOs 3.00 2 3.33 o-12
Military hospital 11.65 5 28.67 O-200 sting patients.
Medical school 11.77 15.48 O-60
Urgent care 9.47 f 28.16 O-125 DISCUSSION
Cumulative 10.38 4 23.23 O-200
An unknown proportion of persons who are stung
N = 124.
SD = Standard deviation. by hymenoptera develop sufficient IgE antibodies to
HMOs = Health maintenance organizations. mediate a Type 1 immediate hypersensitivity reaction
12
upon reexposure to the venom (8). The initial signs
and symptoms of anaphylaxis may include erythema,
pruritus, lightheadedness, and a sense of impending
doom. The cutaneous findings may progress to in-
clude urticaria or angioedema. Hoarseness of voice or
a lump in the throat may signal the development of
laryngeal edema and subsequent upper airway ob-
struction. Bronchospasm may lead to wheeze and
chest tightness. The systemic manifestations of ana-
phylaxis may worsen to include circulatory collapse as
a result of hypotension, dysrhythmia, or asphyxia (9).
The majority of anaphylactic reactions begin within
1 h, making prompt medical care and the practice of
preventive measures timely necessities ( 10).
In 1983, it was reported in a large study that 70%
of deaths were caused by airway obstruction and
24010 of deaths were caused by cardiovascular dys-
function ( 11). On rare occasions, delayed systemic
reactions occurring 2 h to 3 weeks after the sting
are mediated by an IgG and IgM antibody response
causing serum sickness, vasculitis, and nephritis.
Rare idiopathic neurologic complications include
neuritis and encephalitis ( 11,12).
Physicians practicing emergency medicine can
play a vital role in the identification of patients
known to develop anaphylactic reactions; however,
the emergency medicine community must accept the
shared responsibility of providing such care. After-
care instructions should include informing the pa-
tient about how to obtain an identification bracelet
(13). However, 24% of the physicians did not know
where to obtain an anaphylaxis identification brace-
let. This lack of knowledge also has the potential to
affect the care of patients treated for allergic reac-
tions to other substances such as penicillin or food.
Anaphylaxis identification bracelets that describe the
patient’s insect allergy can be obtained by writing to
the Medic Alert Foundation (P.O. Box 1009, Tur-
lock, CA 95380).
A total of 60% of patients who develop systemic
allergic reactions from a hymenoptera sting go on to
develop as severe or more severe reactions with a
subsequent sting (12,14). In addition, cross-antigen-
icity and cross-allergenicity among the venom of
some hymenoptera species can cause a person to re-
act after exposure to a hymenoptera species different
than the initial sensitizing insect ( 15). Immunother-
apy has a 95% success rate for preventing significant
systemic allergic reactions (16).
Aftercare instructions for all patients who develop
an anaphylactic reaction to hymenoptera venom
should include a referral to an allergist for skin test-
ing and possible desensitization immunotherapy.
L. McDougle et al.
However, 74 of the physicians were correct in stating
that patients who develop only a large local reaction
do not require referral to an allergist for skin testing
or desensitization immunotherapy. A large local re-
action is defined as a reaction with swelling and ery-
thema contiguous with the sting site, peaking at 48 to
72 h, and often lasting as long as 1 week ( 17). These
large local reactions are not dependent on IgE anti-
body, and the determination of serum venom-
specific IgE by radioallergosorbent testing (RAST)
or skin testing does not aid in treatment or predicting
prognosis (12,17). The use of venom immunother-
apy does not modify large local reactions, and only a
small minority of patients will develop anaphylaxis
with subsequent stings; therefore, these patients are
not considered candidates for venom skin testing or
desensitization immunotherapy ( 12,17). The after-
care instructions should include written avoidance
measures, and the patient should wear an identifica-
tion bracelet that describes the history of large local
reactions. For acute self-treatment, the patient
should utilize cold compresses, aspirin, and an anti-
histamine ( 12,15 ). Extensively large local reactions
may require treatment with prednisone 40 mg daily
for 2 to 3 d.
Grabenstein and Smith ( 18) report that patients
with a known history of insect sting anaphylaxis who
were given an Epi-pen or Ana-kit reported 0.49 uses
per patient year. Patients with a known history of
hymenoptera sting anaphylaxis should receive a pre-
scription for injectable epinephrine for initial self-
treatment. Following self-treatment, the patient
should promptly go to the nearest emergency depart-
ment, regardless of the response from the initial dose
of epinephrine (10). However, epinephrine must be
given with caution to otherwise healthy individuals
over 35 years of age; it is relatively contraindicated
for the elderly population and for those with known
coronary artery disease, and must be avoided in those
patients presenting with life-threatening tachydysr-
hythmias ( 13). Although there are no adequate well-
controlled studies of epinephrine use in pregnant
women, epinephrine crosses the placenta and its use
during pregnancy may cause anoxia in the fetus. Epi-
nephrine should be used during pregnancy only if the
potential benefit justifies the potential risk to the fe-
tus (19). These patients should receive direct referral
to an allergist for appropriate follow-up manage-
ment .
Seventy-three percent of physicians reported pre-
scribing an Epi-pen or Ana-kit for all patients treated
for hymenoptera sting anaphylaxis. This is in con-
trast to the Hutcheson and Slavin study (5) that was
Hymenoptera Sting Anaphylaxis
Table 4. Avoidance instructions (10,ll)
1. Wear pants and long-sleeve shirts.
2. Insects are attracted to bright colors and floral patterns.
White, green, tan, and khaki are the least attractive colors.
3. Wear shoes outdoors.
4. Avoid yardwork or other activities where insect contact is
frequent.
5. Keep garbage cans away from house.
6. Remove insect-attracting plants from inside and immediate
proximity of the house.
7. Don’t use scented soaps, lotions, or perfumes.
8. Keep car windows closed.
9. Keep doors closed and screens on windows in the house.
10. When confronted by an insect, avoid quick movements and
don’t provoke it. Turn away, lower your face, and walk away
slowly.
11. Have insect nests around the house removed by profes-
sional exterminators.
submitted for publication in 1989, in which 29% of
such patients received an Epi-pen or Ana-kit. This
finding may represent an interval improvement in
this preventive medicine intervention by physicians
practicing emergency medicine, selection bias, or re-
call error.
Aftercare instructions should include written
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13
avoidance measures that should be distributed to all
such patients (Table 4).
In conclusion, this survey substantiates the need
for further educational efforts aimed toward increas-
ing the awareness of patients and physicians alike,
concerning the implications of hymenoptera allergy
and the value of proper preventive measures. This
includes providing written avoidance instructions,
prescribing Epi-pen or Ana-kit for initial self-
treatment, referral to an allergist for skin testing and
possible desensitization immunotherapy, and helping
patients to obtain anaphylaxis identification brace-
lets. Additional research may be required to deter-
mine to what extent such educational efforts improve
the preventive medicine practice of physicians in the
acute care setting.
Acknowledgments-The authors would like to thank the
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