Medications and Honeybee Stings: A Dangerous Combination

On a summer evening in June, you are dispatched for a 67-year-old male unresponsive in the backyard of his residence.

Upon arrival you are waved in by family members who lead you to him. You find him in a beekeeper suit, supine on the ground, with his beekeeper helmet removed.

ASSESSMENT

Your patient presents responsive to pressure stimuli, with a radial pulse at 70 bpm. Respiration is normal, at 12 breaths per minute, facial skin color is red and diaphoresis is noted. The beekeeper suit is cut off and blood pressure obtained. It is 96/68, slightly hypotensive.

Family members tell you he was working with his honeybee hives. He was walking back to the house and said he was stung by a bee when he collapsed. The family shares that he has been stung before and has never had an episode like this.

They say he has no allergy to bee stings and has been a beekeeper for 40 years. Your patient has a history of hypertension. He was recently diagnosed with a fib and he is diabetic. He takes metoprolol, metformin, Eliquis, and lisinopril.

TREATMENT

You begin your treatment: place the patient on oxygen by a non-rebreather mask, establish an IV and give a fluid bolus, due to the blood pressure. You apply the cardiac monitor and note a fib at 75 bpm.

You perform a 12-lead ECG and note no STEMI. You begin transporting your patient to a local hospital for further treatment. Enroute your patient’s condition starts to improve as he starts talking and his blood pressure improves.

UNDERSTANDING

What is going on with your patient? They could be having an anaphylactic reaction, but anaphylaxis usually involves two body systems and causes constriction of the airways, vessel dilation with decrease in blood pressure and tachycardia.1 The only sign or symptom that indicates anaphylaxis is blood pressure.

This patient has been a beekeeper for 40 years and has been stung before with no problems. So how do we explain the red skin and diaphoresis? This could be from being in the beekeeper suit, as the suit is hot and does not have good ventilation.

Or the patient could be suffering from a heat-related emergency. While this is possible, again the heart rate is not elevated, so a heat-related emergency does not seem possible either. Is there any other information we can gather from the patient’s history and medications? The patient is a borderline diabetic but does not take any medication for this.

The patient has recently been diagnosed with a fib and was put on a metoprolol, a beta-blocker. The patient has hypertension and takes hypertensive medication lisinopril. Could these two factors explain the problem?

MEDICATIONS

The patient is on some medications that affect the heart, the blood vessels and blood clotting. The first medication is metoprolol, a beta-blocker that works on the heart and the blood vessels. Metoprolol works by relaxing the blood vessels and slowing the heart rate.2

The second medication is lisinopril, which is used to treat hypertension. Lisinopril is an Angiotensin-Converting Enzyme (ACE) inhibitor and works by decreasing chemicals that cause blood vessels to tighten/constrict, this allows the blood to flow smoothly.3

Both these medications work on the blood vessels to help the heart pump blood more efficiently. Another medication that could be of concern is Eliquis. Eliquis is a b prescribed to prevent blood clots in those people that have atrial fibrillation.

Since the patient has been on these medications for a while the probability of these two medications causing the patient to pass out is not likely.

HONEYBEE STINGS

Honeybees are not usually aggressive. They usually only sting out of self-defense. They have venom sacs attached to the stinger. When they sting, the venom sacs keep pumping venom.4 The venom from a bee sting can trigger an allergic reaction and possibly an anaphylactic reaction. It is made up of many chemicals and compounds.

One of the most abundant compounds in bee venom is melittin.4 Almost immediately, the bee sting causes pain and edema around the sting site. However, what is happening under the skin is the true cause of the problem. The injected melittin causes the red blood cells at the site to burst and the capillaries at the site to expand.4

When the bee stings, the enzymes from the venom begin to degrade the surrounding tissue. The body starts to fight the bee sting by using the body’s immune response to fight the bee sting.3 Once a bee stings a person the body starts to release histamine, and the blood vessels begin to dilate, and skin starts to turn red.

Since the venom is being pushed through the body and the venom sacs are pushing more venom into the site, an increase in vasodilation at the site of the sting takes place, and the body’s response increases. The effect on the microcirculation causes small vasodilation, which the body wants to respond to.

THE BODY’S RESPONSE

In EMT class, we learned about the sympathetic nervous system, including fight-or-flight response. The bee sting activates the system, and the body responds by increasing the heart rate.1

As we know, the body has mechanisms in place to monitor vasodilation—and to respond to that vasodilation. Baroreceptors monitor the blood pressure inside the vessels and send messages to alter peripheral vascular resistance and cardiac output.1

The blood vessels will constrict down to increase peripheral vascular resistance and the heart rate will increase to increase cardiac output. Maintaining blood pressure to perfuse the vital organs is the highest priority.

The body, however, cannot do what it normally does because of the medications, metoprolol and lisinopril. These medications affect the blood vessel’s ability to constrict and cannot increase peripheral vascular resistance.

Since the vessels are not constricting properly, the blood pressure responds by dropping out of normal range. Metoprolol also affects the heart rate’s ability to increase—and keeps the heart rate down. The decrease in blood pressure and the heart does not increase.

This means the brain is not getting enough oxygen rich blood. This will cause the body to shut down and the patient will go unresponsive.

TREATMENTS

Since the bee venom and the medications are causing the problem, your focus in treatment should be maintaining blood pressure and oxygenation. Begin with the ABCs.

Airway: If the patient has an airway and is breathing adequately, provide high flow oxygen with a non-rebreather mask.
Blood pressure: Check the circulation if the patient has a pulse and inadequate circulation establish an IV and give fluid to increase blood pressure. With older patients, be careful with the fluid. If you give a bolus assess the lungs before and after the bolus.
Cardiac monitor: Place the patient on the cardiac monitor and perform a 12-lead to rule out any myocardial infarction.

Based upon your protocols, you can consider epinephrine. You can also contact medical control to give epinephrine even though this is not true anaphylaxis. Epinephrine has both alpha and beta properties that would help with vasoconstriction and increasing the heart rate.1

The epinephrine will help overcome the beta-blocker and increase the blood circulation. Transport and monitor your patient. Be prepared: Your patient may be critical and may need further treatment.

AN UPDATE

This patient was my uncle. He could not understand what happened. He had been stung before and never had an issue. This incident happened after he went on metoprolol.

Two weeks later he suffered the same episode after being stung while walking across the yard. Again, symptoms were the same and 911 responded.

The vitals at the time included the following:

Heart rate: normal.
Blood pressure: low.
Respirations: normal.
Skin: red and diaphoretic.

He was transported to the hospital for a second time. An allergy test for bee stings was recommended, and he received this. He was also given an epinephrine autoinjector. The allergy test was negative for allergy to any bee stings, and he was referred to his cardiologist.

His cardiologist decreased the metoprolol dosage. He did have one more episode after being stung by a hornet. This time he knew what to expect.

So he went into his house and sat in a chair. He remained at home and after 30 minutes returned to normal mental status. He had abIation for his a fib and was taken off metoprolol. He has not suffered another episode.

THE BIG PICTURE

The bee venom is causing micro vasodilation, and the medications are affecting the body’s ability to respond and keep the body properly perfused. Hypertensive medications cause vasodilation to decrease the pressure inside the vessel.1

Beta-blockers can affect both heart and blood vessels, which can have an impact on the hearts’ ability to increase and the blood vessel’s ability to respond to vasodilation.

Without proper perfusion the body cannot maintain the vital functions. The vital organs are deprived of oxygen-rich blood, and the result will be a patient that goes unresponsive.

This result is not exclusive to bee stings. This can happen with anything that causes the body to become hypovolemic. As advanced life support providers, we need to think critically.

REFERENCES

1. Mistovich, J, (2024). Prehospital Emergency Care (12th Edition). Pearson Education

2. MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US); [2023 Sept 15] Metoprolol. https://medlineplus.gov/druginfo/meds/a682864.html

3. MedlinePlus [Internet]. Bethesda, MD; national Library of Medicine (US); [Revised 2021 Feb 15]. Lisinopril. https://medlineplus.gov/druginfo/meds/a692051.html

4. Riddle, S, (2016, June). Bee Venom and The Chemistry of Ouch. Bee Culture the Magazine of American Beekeeping. https://beeculture.com/bee-venom-chemistry-ouch/.

5. Cleveland Clinic 6/23/2022 https://my.clevelandclinic.org/health/diseases/23352-vasodilation.

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