OBJECTIVE Hymenoptera stings are thought to cause systemic allergic reactions in 0.4-5% of individuals, and to account for 40-100 deaths annually in the USA. This review examines current research on insect-sting anaphylaxis in the emergency department (ED), and provides suggestions on how to improve ED treatment and prevention. RESULTS Few published studies since January 2005 examine the emergency management of insect-sting allergic reactions. Earlier studies found that few ED patients with this problem received health education, a prescription for self-injectable epinephrine or referral to an allergy specialist at ED discharge. A recent multicenter study by our group demonstrated that ED patients with insect-sting allergic reactions continue to receive care discordant with national guidelines for the emergency management of anaphylaxis. CONCLUSIONS Concordance with national guidelines for the treatment of anaphylaxis remains poor among insect-sting allergy patients. The development of a simple, clinical definition of anaphylaxis is urgently needed to facilitate identification of cases. Such a definition would help tremendously with dissemination of emergency management guidelines and the creation of systems for their implementation. All of these steps are essential for the improved treatment and prevention of insect-sting anaphylaxis in the ED.