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• Stinging insects belong to the order Hymenoptera, and are divided into three families:
  1) vespidae, 2) apidae, and 3) formicidae.
• The vespids include yellow jackets, hornets, and wasps.
• The apids include honeybees and bumblebees.
• The formicids include the stinging ants. These ants sting repeatedly in a circular pattern, while holding on with their mouth.
• Hymenoptera are social creatures that sting to protect their nest, hive, or colony.
• Yellow jackets nest in the ground, and are easily disturbed by lawn mowers and other yard activities. They are very aggressive stinging insects. They are attracted to picnic areas, garbage, sugary food, and soda cans.
• Hornets form large paper nests in trees and shrubs.
• Wasps are hairless and have a narrow “waist.” They form paper nests under roof overhangs and eaves of buildings. Wasps feed on nectar and arthropod larvae.
• Honeybees have hairy bodies, and leave their stinger behind after they sting. They are not naturally aggressive, however. Their beehives are large. The Africanized “killer” honeybees are more aggressive, and attack in swarms. They fly at only 4 miles per hour, allowing most victims to flee.
• Imported fire ants build earthen mounds that may contain more than 100,000 ants. They attack in large numbers. Infants and elderly people are at risk for being attacked by fire ants because they have limited mobility.
  
  HOW DO BEES AND INSECTS STING?
• Bees and wasps have a stinger that is a modified ovipositor. They puncture the skin with a hollow stinger, and inject the venom into the victim.
• Bees leave their barbed stinger in the skin, along with the attached venom glands, nerves, and muscles. This action eviscerates the bee and kills it. Nearly all of the bee sting venom is injected within 10 to 20 seconds. For this reason, it is very important to remove the stinger as soon as possible – by any means necessary.
• Vespids, on the other hand, have a smooth stinger, which allows them to sting repeatedly.
• Fire ants (Solonepsis invicta) attack in large numbers, inflicting thousands of stings and bites to victims unable to escape. Fire ants bite with their mandible (mouth) – then sting repeatedly in an arc around the bite site. Their stings develop into sterile pustules, and then rupture. Infants often scratch open fire ant wounds, which causes secondary infections. Severe anaphylaxis has been reported in up to 4% of imported fire ant stings. Toxic reactions occur when a large number of ants sting an infant or elderly person.
  
  WHAT IS HYMENOPTERA VENOM?
• The venom of winged Hymenoptera (bees, wasps, ants) contains over 30 individual components, including: proteins, peptides, biogenic amines, and enzymes.
• All venom allergens are proteins, and most of them are also enzymes.
• The major allergens in honeybee venom are:
  hyaluronidase and phospholipase A2.
• The major allergens in wasp venom are:
  antigen 5, histamine, phopholipase, bradykinin, dopamine, acetylcholine, and serotonin.
• Fire ant venom is 95% water-insoluble alkaloid, and 5% water-soluble allergenic protein. The alkaloids do not cause an IgE antibody response, however.
• Hymenoptera venom initially acts by disrupting the cell membranes of the body.
• The vasoactive amines – hydroxytryptamine, histamine, norepinephrine, and dopamine – are responsible for local sting reactions.
• Most serious reactions are caused by true IgE allergic mechanisms that activate mast cell degranulation.
  
  THE BODY’S REACTION TO BEE AND INSECT STINGS
• The body reacts to a Hymenoptera sting in one of the following ways:
  immediate usual, large local, systemic anaphylactic, toxic, or delayed reaction..
• 1) Immediate usual reaction:
  Pain, erythema, and swelling at the sting site. This normal reaction resolves within a few hours. It is cause by the venom’s vasoactive amines.
• 2) Large local reaction:
  More extensive swelling and erythema around the sting site. The reaction may take several days to resolve. It may be misdiagnosed as cellulitis.
• 3) Systemic anaphylaxis reaction:
  The most severe response. Classic IgE-mediated reaction. Fatalities are usually caused by airway obstruction or shock. Most fatalities occur in adults.
• 4) Toxic reaction:
  This is the result of the physiologic effects of very high concentrations of venom - which occurs after multiple bee, ant, or wasp stings. It usually causes vomiting, diarrhea, headache, and fever. It may occasionally cause hemolysis, rhabdomyolysis, or intravascular coagulation.
• 5) Delayed reaction:
  This problem may develop several days after the sting. A child may develop influenza-like symptoms.
  
  THE ANAPHYLAXIS EMERGENCY
• Anaphylaxis is an extreme reaction of the immune system. It is the most serious response to a bee or insect sting. It has very profound respiratory and cardiovascular effects, such as airway obstruction and severe hypotension.
• Other effects of anaphylaxis include:
  loss of consciousness, shock, swelling of the lips and eyes, hives, and dizziness.
• Anaphylaxis occurs with 0.5% to 1.5% of stings. Death from a bee or insect sting almost always occurs within the first hour. Airway obstruction is the most frequent cause of death from anaphylaxis.
• IgE antibiotics can be produced to a variety of allergen, including bee and insect venom. IgE antibodies are bound to mast cells and circulating basophils.
• Re-exposure to the venom leads to “mediator release” when the mast cells and basophils degranulate. Histamine is the most common preformed mediator in mast cells.
  
  FIRST AID FOR BEE AND INSECT STINGS
• 1) Remove the bee stinger as quickly as possible – by any means necessary. Pinching the stinger to remove it is also an acceptable technique, since time is of the essence.
• 2) Check the child’s airway, breathing, and circulation.
• 3) Apply cool ice packs, or apply a paste made of baking soda and vinegar.
• 4) Elevate the arm or leg to limit swelling.
• 5) Give acetaminophen for relief of pain.
• 5) Inject the child with his epinephrine auto-injector if needed.
• Call your physician or 911 immediately if:
  the child has difficulty breathing or swallowing,
  the child collapses,
  the child has extreme swelling around the eyes or lips,
  the child has hives all over the body.
  
  HOSPITAL TREATMENT FOR BEE AND INSECT STINGS
• 1) Assess the child’s airway, breathing, circulation, level of consciousness, and capillary perfusion.
• 2) Measure and record all vital signs, especially blood pressure and body weight.
• 3) Administer aqueous epinephrine (1:1000) at a dose of 0.01 mg/kg if anaphylaxis is suspected. Epinephrine is injected intramuscularly, subcutaneously, or sublingually. This dose can be repeated every 15 minutes if necessary.
• 4) Administer an antihistamine (diphenhydramine) orally, or by injection at 1 mg/kg.
• 5) Provide an initial IV bolus of 10-20 ml/kg of isotonic crystalloid, in addition to the epinephrine and diphenhydramine.
• 6) The child should also receive:
  intructions on avoiding stings, information on obtaining a Medic-Alert tag, a prescription for self-administered epinephrine, and a referral for an immunology evaluation.
  
  PREVENTION OF BEE AND INSECT STINGS
• Be very careful with food and open soda cans. Do not drink from open beverage cans outdoors, because this attracts insects.
• Avoid exposed food or garbage at picnics. Keep garage and patio areas clean. Keep garbage cans tightly sealed.
• Do not allow your child to walk barefoot or wear sandals outdoors. Give your child shoes to wear.
• Give your child a hat to wear outdoors.
• Avoid wearing floral patterns or bright-colored clothes outdoors. White and khaki are the best colors for preventing insect stings.
• Avoid using hair spray, wet-smelling perfumes and colognes.
• Make sure that your child avoids rapid movements and arm-flailing when near stinging insects.
• Do not use noisy equipment, such as lawn movers within 50 years of beehives, or within 150 yards of Africanized bee colonies.
• Remember that most insect repellents are not effective against stinging insects.
  
  An article in The Medical Journal of Australia describes a patient with anaphylaxis as a result of S. invicta (imported fire ant) stings, and documents his treatment.
  
  Solley GO, Vanderwoude C, Knight GK: Anaphylaxis due to Red Imported Fire Ant sting. The Medical Journal of Australia 3 June 2002 176 (11): 521-523.
  
  
  

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