Asploro Journal of Biomedical and Clinical Case Reports

Asploro Journal of Biomedical and Clinical Case Reports

E Pan¹, Tao Cheng¹, Yao Chen¹, Bin He^1*
1Emergency Department, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China

Corresponding Author: Bin He
Address: Emergency Department, Sichuan University West China Hospital, No. 37, Guoxue Alley, Wuhou District, Chengdu, Sichuan Province, 610041 China.
Received date: 09 December 2024; Accepted date: 30 December 2024; Published date: 06 January 2025

Citation: Pan E, Cheng T, Chen Y, He B. Emergency Treatment and Management Strategies for 79 Patients Involved in a School Mass Bee Sting Incident. Asp Biomed Clin Case Rep. 2025 Jan 06;8(1):38-43.

Copyright © 2025 Pan E, Cheng T, Chen Y, He B. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium provided the original work is properly cited.

Keywords: Mass Bee Sting, Emergency Treatment, Scoring Assessment, Graded Management, Emergency Strategy

Abstract

Objective: To analyze the emergency treatment and triage strategies for patients involved in a mass bee sting incident at a school and to evaluate the effectiveness of optimizing emergency procedures through scoring-based assessment criteria. The aim is to reduce the incidence of severe complications and improve the efficiency of emergency response during mass casualty events.
Methods: A retrospective analysis was performed on the clinical data of 79 patients affected by bee stings during a mass incident at a school. Demographic information, clinical presentations, scoring results, classifications, and treatment measures were collected and analyzed. The severity of each patient’s condition was assessed using the Quick Sequential Organ Failure Assessment (qSOFA) score and an allergy response score. Based on these scores, patients were categorized as mild, moderate, or severe, with emergency treatment tailored accordingly. Mild cases presented with skin symptoms, moderate cases involved respiratory distress or mental disturbance, and severe cases showed multiple organ damage or anaphylactic shock. Emergency interventions, including triage labeling, intravenous access, anti-allergic medication, corticosteroid administration, and dynamic monitoring, were applied based on condition severity. Treatment outcomes and the value of the scoring system were subsequently analyzed.
Results: The application of scoring-based assessments made emergency triage more systematic and rational. Severe cases received priority interventions such as intravenous access, vasopressor administration, and oxygen therapy to maintain vital signs. Moderate cases were treated with anti-allergic medications and symptomatic management following intravenous access establishment, whereas mild cases were managed through observation and symptomatic relief. Most patients experienced significant symptom improvement after graded treatment, with a few severe cases requiring hospitalization, all of which exhibited favorable outcomes.
Conclusion: The implementation of scoring-based assessments for graded emergency treatment significantly enhances the efficiency of emergency responses in mass bee sting incidents and effectively reduces the risk of complications. This approach provides a scientific basis and a feasible strategy for managing similar mass casualty events in the future.

Clinical Data

General Information:

This mass bee sting incident involved 79 patients from two to three classes of the same school. Of these patients, 49 were male and 30 were female. Apart from three teachers, the remaining patients were students. The age range of patients was 14 to 53 years, with a mean age of 17.5 ± 7.03 years. Most patients had no prior medical history, and the emergency consultation time ranged from 0.5 to 2 hours post-injury. All patients underwent treatment to remove bee stingers; in some cases, stingers remained embedded in the sting sites. The stings primarily affected exposed body areas, including the head, face, neck, back, waist, and limbs. Clinical manifestations varied, with the primary symptoms being pruritus and pain (51 cases), dizziness and fatigue (35 cases), dyspnea (9 cases), localized swelling (31 cases), blisters (3 cases), subcutaneous hemorrhage (1 case), palpitations (1 case), chest pain (1 case), and confusion (1 case). Initial assessment grading was performed using the qSofa scale, with 65 cases scoring less than 1, 12 cases scoring 1, and 2 cases scoring greater than or equal to 2. All patients received anti-allergic treatment, with 75 receiving corticosteroid therapy, 70 receiving sodium bicarbonate, 5 receiving promethazine, 2 receiving epinephrine, and 1 receiving dopamine.

Treatment Process:

Preliminary Assessment and Classification:

Upon receiving notification of the need for emergency treatment for a large number of bee sting patients, the emergency department immediately formed a mass incident response team, maintaining a nurse-to-patient ratio of 1:10 for triage. Medical staff conducted preliminary assessments and classifications based on the Quick Sequential Organ Failure Assessment (qSOFA) score and the severity of allergic reactions. Mild patients were assessed on the basis of a qSofa score of less than 1 or no more than 10 stings, and the anaphylactic reaction manifested primarily as skin lesions. Moderate patients were assessed on a qSofa score of 1 or more than 10 stings, or fewer than 10 stings with symptoms such as psychiatric abnormalities, dyspnoea, soya sauce-coloured urine, black stools, or a combination of other systemic injuries in addition to skin injuries. Severe patients present with a qSofa score of greater than or equal to 2 or multiple organ injuries, impaired consciousness, anaphylactic shock, or unstable vital signs. Based on these classifications, patients were assigned to different waiting areas. Severe patients were directed to the resuscitation room and given a red identification band; if their condition did not improve within a short period after evaluation, they were admitted to the hospital. Moderate patients were assigned to an observation room, given a yellow identification band, and treated with a nurse-to-patient ratio of 1:2.5. Mild cases were directed to the general diagnosis room and given a green identification band. Additionally, patients with prescriptions or test requests marked with a “mass incident” seal were given priority by auxiliary departments.

Treatment Measures:

For severe patients, medical staff established intravenous access, opened the airway, and provided oxygen support within 5 to 10 minutes. Anti-allergic and volume expansion therapies were initiated immediately to mitigate allergic reactions and maintain circulatory function. Vasopressors were administered as needed to stabilize vital signs. Moderate patients had intravenous access established within 30 minutes and received anti-allergic treatment and symptomatic management to control allergic reactions and symptoms. Mild patients were treated in sequence and dynamically observed for any changes in their condition. If their condition worsened, they were promptly transferred to the observation room for further monitoring and treatment. All patients underwent thorough bee stinger removal, and external or oral Qingdingsheng Sheyao (anti-toxin medication) was used as needed. Detailed medical histories were taken, and physical examinations were performed, with vital signs monitored and identification bands applied. Laboratory tests, including blood counts, liver and kidney function tests, electrolytes, cardiac markers, and urinalysis, were performed to assess each patient’s condition comprehensively. Clinical presentations and laboratory results indicated that allergic dermatitis was the most likely diagnosis for most patients. Consequently, all patients received loratadine for anti-allergic treatment, combined with prednisone acetate glucocorticoids to reduce inflammation, and sodium bicarbonate to alkalize urine. Patients experiencing significant pain received dezocine via intramuscular injection, while four patients with infections received ceftriaxone antibiotics. Patients with subcutaneous hemorrhage did not receive corticosteroids temporarily. Additionally, fluid resuscitation, electrolyte supplementation, and short-acting insulin therapy were provided as needed, based on assessments of electrolyte levels, blood glucose, and urine output. In the observation room, due to the large number of patients, in order to rationally allocate medical resources, those with a qSofa score of 1 were placed on cardiac monitoring, given oxygen support, and dynamically monitored for changes in their condition, while all other patients were dynamically assessed according to the Bee Sting Code of Practice 2021 at 6, 24, 48, and 72 hours, respectively, and the risk of the disease was stratified again according to the results of the assessment. Patients whose conditions worsened were promptly transferred to the resuscitation room, while those showing improvement were discharged from the observation room or sent home to avoid overtreatment or undertreatment, thereby minimizing the risk of organ failure.

Post-Treatment Nursing Measures:

Post-treatment measures included: (1) close monitoring of vital signs, including temperature, blood pressure, and electrocardiogram changes for patients in the observation room. Airway patency was ensured, and any instances of laryngeal edema or respiratory difficulty were promptly reported to a physician; tracheotomy was performed if necessary. (2) Urine output was dynamically monitored to detect potential acute renal failure, and hemodialysis was initiated if required to reduce toxin-induced organ damage. (3) Patients with significant pruritus were treated with calamine lotion and advised to avoid scratching to prevent secondary infection. (4) Patient education about bee stings was enhanced to alleviate negative emotions and improve treatment compliance. (5) A light diet was recommended, avoiding spicy or irritating foods to reduce the risk of allergic reactions.

Results

Among the 79 patients, 31 mild cases were discharged with medication after diagnosis and treatment. Forty-six moderate patients were admitted to the observation room for treatment and dynamic assessment, and were discharged in stages: 6 patients were discharged after 6 hours, 18 after 24 hours, 21 after 48 hours, and 1 after 72 hours. Two severe cases recovered and were discharged after 7 days of hospitalization. Ultimately, all 79 patients made a full recovery, with no recurrence of symptoms and maintained a good mental state.

Discussion

This study explored treatment strategies for mass bee sting incidents from four perspectives: emergency triage, dynamic monitoring, individualized treatment, and integration of emergency resources. The complexity of bee sting pathogenesis and the unpredictability of disease progression make treating large-scale mass incidents a balance between speed and precision [1]. In this study, the application of scoring-based classification and dynamic management improved treatment efficiency, resulting in significant symptom relief for all patients and a high success rate, demonstrating the effectiveness and feasibility of graded treatment strategies.

The pathogenesis of bee stings involves complex immune and metabolic reactions [2]. Bee venom primarily consists of peptides (e.g., melittin), enzymes (e.g., phospholipase A2, hyaluronidase), and non-peptide, non-enzyme substances (e.g., histamine and catecholamines) [3]. These toxic components act directly on cell membranes and vascular endothelial cells, rapidly increasing membrane permeability, leading to cell leakage, tissue edema, and hemolysis, and may even cause acute tubular necrosis [4]. The peptides and enzymes not only induce hemolysis but also promote the release of myoglobin into the bloodstream, leading to myoglobinuria and acute kidney injury, which explains the occurrence of acute tubular injury in some patients. Studies have shown that systemic bee stings can trigger systemic inflammatory response syndrome (SIRS), which poses a greater threat to adolescents whose immune systems are not fully developed [5]. Rapid identification of the risk of multiple organ damage and early intervention with preventive treatment are key to managing mass bee sting incidents.

Compared with the traditional emergency treatment process, this study completed the triage of all patients within 30 minutes of admission, which significantly shortened the time from triage to treatment and rationally allocated healthcare resources (31 cases in the general diagnostic room, with a healthcare-to-patient ratio of 1:1:10; 46 cases in the observation room, with a healthcare-to-patient ratio of 1:2:5; and 2 cases in the resuscitation room, with a healthcare-to-patient ratio of 1:5:2), benefiting from the qSOFA score and the anaphylactic reaction severity score grading system was applicable in the large-scale rescue treatment of this study. The qSOFA score is simple and quick, making it suitable for the preliminary assessment of patient risk within a short time frame [6]. However, the predictive efficiency of qSOFA has certain limitations, particularly for severe patients with insidious progression, who may be misclassified as having mild or moderate symptoms during early assessment. Therefore, future optimization of the scoring system should consider incorporating serum biomarkers such as myoglobin, C-reactive protein (CRP), and interleukin-6 (IL-6), which have high specificity for acute inflammation and organ damage [7]. Combining serum biomarkers with the grading system could not only improve the accuracy of early identification but also provide more reliable data for prognosis management of moderate and severe patients.

The suddenness and complexity of mass bee sting incidents underscore the critical need for dynamic monitoring during treatment [8]. The multiple time-point evaluations at 6, 24, 48, and 72 hours adopted in this study provided a scientific basis for dynamic, stratified patient management. The advantage of dynamic evaluation lies in its ability to promptly identify patients with worsening conditions and rapidly implement interventions. In this study, none of the moderate cases progressed to severe conditions, indicating that phased evaluation effectively controlled disease progression. However, considering the varying risk profiles and rates of symptom progression among patients, future refinements could include more specific time points and assessment frequencies. For instance, clinical literature suggests that the immune response to acute bee stings can peak within 2 to 3 hours; therefore, for high-risk patients, more intensive monitoring during the first 6 hours could ensure a rapid response to symptom exacerbation [9]. Future studies may also consider using wearable biosensors to record changes in vital signs in real time, thereby enhancing the accuracy and convenience of dynamic monitoring.

Resource allocation is crucial in emergency management, particularly in mass incidents where rapid mobilization and interdepartmental cooperation are essential [10]. In this study, the preliminary diagnosis and treatment of 79 patients were completed within 30 minutes due to the hospital’s rapid initiation of emergency procedures, which included full coordination among auxiliary departments and efficient resource integration. The allocation of different medical staff ratios during triage optimized the use of medical resources, thereby improving the speed of emergency response [11]. The rapid response and resource mobilization by auxiliary departments played a key role, as departments such as the laboratory, pharmacy, and blood bank ensured that patients received necessary medication and treatment support in a short time [12]. Future emergency plans could incorporate pre-established multi-scenario simulations to ensure appropriate procedures are quickly initiated under different circumstances, and regular cross-departmental collaboration drills could provide a more solid foundation for responding to large-scale incidents.

Individualized treatment for bee stings was effectively applied in this study. The allergic response to bee venom varies among patients due to differences in constitution and exposure dose [13]. This study employed individualized approaches, including anti-allergic therapy, hormonal intervention, and urine alkalization with sodium bicarbonate. For patients with severe acute reactions, intravenous anti-allergic drugs and corticosteroids were administered. Hormone therapy was particularly effective in managing the risk of acute anaphylactic shock [14]. However, since hormonal interventions can cause adverse effects, careful consideration of dosage and timing is necessary. For future emergency treatment, it is recommended to tailor treatment based on patients’ immune status and medical history. Further clinical research could optimize the timing and dosage of anti-allergic drugs and hormonal interventions to maximize treatment efficacy.

In addition, health education and psychological intervention before discharge are crucial for long-term recovery [15]. The psychological impact of bee sting incidents, particularly on adolescents, should not be overlooked. In this study, education on bee sting prevention and response measures was provided to patients before discharge, helping them develop proper awareness of protective actions and reducing fear of similar incidents in the future. Health education not only improved patient compliance but also enhanced psychological resilience. Future efforts could include long-term follow-up to track patients’ psychological recovery and understand the long-term impact of mass incidents on mental health. Incorporating mental health education into hospital emergency management systems could provide comprehensive health support for patients.

Although this study achieved promising results in graded treatment, there is still room for improvement. The predictive efficiency of the qSOFA score during the acute phase is limited, posing a risk of missed diagnoses. Future enhancements could include incorporating additional inflammatory markers and artificial intelligence algorithms into the rapid assessment system to improve risk prediction accuracy. Additionally, to address training needs during the treatment process, hospitals could conduct regular simulation training for emergency events to enhance teamwork and emergency response capabilities, leading to more efficient handling of mass incidents.

In conclusion, this study presented an efficient emergency treatment model for mass bee sting incidents using scientific graded treatment, dynamic monitoring, resource integration, and individualized care. Future integration of intelligent diagnostics and data analysis technologies could further optimize graded management and individualized treatment strategies in public health emergencies, enhancing the accuracy and efficiency of emergency response and providing systematic guidance for managing complex mass incidents.

Funding

Sichuan Natural Science Foundation Youth Fund project: Project number 23NSFSC4251.

Conflict of Interest

The authors have read and approved the final version of the manuscript. The authors have no conflicts of interest to declare.

References

[1] Charoenwikkai S, Intapun P, Lao-Araya M. Bee Sting Injuries in Thailand’s High Apicultural Area: Outcome, Risk and Treatment Patterns. Risk Manag Healthc Policy. 2024 Jul 17;17:1837-45. [PMID: 39050091]

[2] Shoshany TN, Syed ZA. Ocular Bee Sting. N Engl J Med. 2024 Jun 27;390(24):e64. [PMID: 38912652]

[3] Cui Z, Zhou Z, Sun Z, Duan J, Liu R, Qi C, Yan C. Melittin and phospholipase A2: Promising anti-cancer candidates from bee venom. Biomed Pharmacother. 2024 Oct;179:117385. [PMID: 39241571]

[4] Waziri B, Alhaji UI, Oduwale MA, Umar HI, Abdulmalik AM. A rare concurrence: bee venom associated acute tubular necrosis and acute interstitial nephritis. Oxf Med Case Reports. 2022 May 23;2022(5):omac026. [PMID: 35619680]

[5] Smeding C, van Iterson M, Gamadia LE, Innemee G, Heidt J. Wespen- en bijensteken met ernstige gevolgen [Wasp and bee stings with serious consequences]. Ned Tijdschr Geneeskd. 2020 Nov 12;164:D4990. Dutch. [PMID: 33201621]

[6] Günaydın YK, Kocaşaban DÜ, Güler S, Demirtaş E, Çövüt Y, Öztürk MC, İlgün JD, Akıllı NB. Importance of qSOFA Score in Terms of Prognosis and Mortality in Critical Care Patients. Yonago Acta Med. 2024 Aug 27;67(3):225-32. [PMID: 39193134]

[7] Liu Z, Meng Z, Li Y, Zhao J, Wu S, Gou S, Wu H. Prognostic accuracy of the serum lactate level, the SOFA score and the qSOFA score for mortality among adults with Sepsis. Scand J Trauma Resusc Emerg Med. 2019 Apr 30;27(1):51. [PMID: 31039813]

[8] Wang F, Lv Z. A patient suffered a second myocardial infarction after a bee sting: a case report. J Int Med Res. 2024 Jun;52(6):3000605241259428. [PMID: 38844785]

[9] Lee JH, Kim MJ, Park YS, Kim E, Chung HS, Chung SP. Severe Systemic Reactions Following Bee Sting Injuries in Korea. Yonsei Med J. 2023 Jun;64(6):404-12. [PMID: 37226567]

[10] Porzi J, Porzi M, Patonnier M, Macri F, Widmer N, Desmettre T, Platon A, Poletti PA, Gartner BA. Diagnostic et prise en charge en urgence des incidents radiologiques [Diagnosis and emergency management of radiological incidents]. Rev Med Suisse. 2024 Aug 21;20(883):1418-21. French. [PMID: 39175292]

[11] Eraybar S, Dal E, Aydin MO, Begenen M. Transforming emergency triage: A preliminary, scenario-based cross-sectional study comparing artificial intelligence models and clinical expertise for enhanced accuracy. Bratisl Lek Listy. 2024;125(11):738-43. [PMID: 39487846]

[12] Craca M, Coccolini F, Bignami E. Artificial intelligence may enhance emergency triage and management. J Trauma Acute Care Surg. 2023 Jun 1;94(6):e46-47. [PMID: 36880782]

[13] Tsuruta K, Yokoi K, Yoshioka G, Chen W, Jojima K, Hongo H, Natsuaki M, Sonoda S, Kounis NG, Node K. Different types of Kounis syndrome caused by different episodes of bee sting anaphylaxis: Misfortunes never come singly. J Cardiol Cases. 2022 Mar 26;26(1):81-84. [PMID: 35923521]

[14] McGrath FM, Francis A, Fatovich DM, Macdonald SP, Arendts G, Woo AJ, Bosio E. Genes involved in platelet aggregation and activation are downregulated during acute anaphylaxis in humans. Clin Transl Immunology. 2022 Dec 26;11(12):e1435. [PMID: 36583159]

[15] Burke J, Corrigan S. Bee Well: a positive psychological impact of a pro-environmental intervention on beekeepers’ and their families’ wellbeing. Front Psychol. 2024 Mar 27;15:1354408. [PMID: 38601827]