When the Swarm Reaches the Emergency Department - Allergy & Clinical Immunology clinical simulation case. A 58-year-old male farm worker who received...
Age: 58 • Gender: Male • Setting: Emergency Triage
Clinical Presentation & History
A 58-year-old male farm worker who received approximately 40 honeybee stings over the head, neck, and extremities when a harvester disturbed an apiary colony. He presents with diffuse urticaria, wheezing, hypotension, angioedema of the lips, and impending airway compromise from multiple systemic reactions occurring simultaneously.
Acute Resuscitation Milestones & Priorities
Clinical phases and key interventions encountered in this emergency module:
Mass Casualty Triage & Systemic Anaphylaxis Recognition
Venom Mass Resuscitation, Population Triage & Disposition
High-Yield Clinical Pearls
Mass envenomation (>40 stings) and anaphylaxis are distinct pathophysiologic entities that can coexist; epinephrine treats anaphylaxis, while supportive care treats venom toxicity.
The strongest risk factors for fatal anaphylaxis are age > 50, asthma, and delayed or absent epinephrine administration.
IM epinephrine into the anterolateral thigh is the guideline-supported first-line intervention; IV epinephrine bolus is reserved for cardiac arrest or refractory shock.
Biphasic anaphylaxis occurs in up to 20% of patients, typically within 4–12 hours, mandating structured observation even after symptom resolution.
In asthmatic anaphylaxis with refractory bronchospasm, IV magnesium sulfate (2 g over 20 min) and ketamine induction provide bronchodilation.
Population-level disaster triage for anaphylaxis prioritizes the elderly and those with cardiopulmonary comorbidities over sting count alone.
Concurrent rhabdomyolysis and hemolysis from massive envenomation require aggressive isotonic fluid resuscitation, urine alkalinization consideration, and renal/hematologic monitoring.
Test Your Clinical Reasoning in Real Time
Step into the active clinician role for this case. Order diagnostic tests, analyze live laboratory panels, and navigate branching clinical decisions with real-time feedback.