What is included in emergency department (ED) care for insect bites?

Updated: Jun 21, 2018
  • Author: Boyd (Bo) D Burns, DO, FACEP, FAAEM; Chief Editor: Joe Alcock, MD, MS  more...
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Endotracheal intubation and ventilatory support may be required for severe anaphylaxis or angioedema involving the airway.

Treat emergent anaphylaxis in an atopic individual with an initial intramuscular injection of 0.3-0.5 mL of 1:1000 epinephrine. This may be repeated every 10 minutes as needed. Note that insect bites only rarely cause anaphylaxis compared with stings; refer to Hymenoptera Stings.

A bolus of IV epinephrine (1:10,000) may be used cautiously in severe cases. Solution of 1:10,000 typically is found in 10-mL vials. Repeated 1-mL doses are a reasonable initial approach in a critically ill patient with anaphylaxis. Once a positive response is achieved, these boluses can be followed by a carefully monitored, continuous epinephrine infusion. Use extra care in monitoring formulation, concentration, and dose when administering IV epinephrine to avoid inadvertent overdose.

Severely hypotensive patients may require a large volume of IV fluids. Monitor for angioedema and pulmonary edema.

Antihistamines, both H1 and H2 blockers, are useful in treating systemic reactions. Diphenhydramine is commonly used in the emergency department, but cetirizine should also be considered in patients not requiring intravenous medications, as it is equally efficacious, has a similar onset of action, and has a longer duration. Corticosteroids also are often used in such patients.

Refer to Anaphylaxis and Serum Sickness for further guidance.

Ensure appropriate tetanus prophylaxis.

Undefined erythema and swelling seen may be difficult to distinguish from cellulitis. As a general rule, infection is present in a minority of cases and antibiotic prophylaxis is not recommended.

Related diagnostic and treatment guidelines are available on anaphylaxis, travel medicine, and referral guidelines (also see Further Reading). [20, 21, 22]

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