NASA/TM-2012-217362

Anaphylaxis, Intra-abdominal Infections, Skin Lacerations, 

and Behavioral Emergencies: A Literature Review of 

Austere Analogs for a Near Earth Asteroid Mission 

Natacha G Chough, M.D.

Stanford University Hospitals and Clinics

Division of Emergency Medicine

Stanford-Kaiser Emergency Medicine Program

Sharmi Watkins, M.D., M.P.H.

Element Scientist, Exploration Medical Capability

The University of Texas Medical Branch

NASA/Johnson Space Center Bioastronautics Contract

Anil S Menon, M.D., M.S., M.P.H.

Physician-Scientist, Exploration Medical Capability

The University of Texas Medical Branch

NASA/Johnson Space Center Bioastronautics Contract

August 2012
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NASA/TM-2012-217362

Anaphylaxis, Intra-abdominal Infections, Skin Lacerations, 

and Behavioral Emergencies: A Literature Review of 

Austere Analogs for a Near Earth Asteroid Mission 

Natacha G Chough, M.D.

Stanford University Hospitals and Clinics

Division of Emergency Medicine

Stanford-Kaiser Emergency Medicine Program

Sharmi Watkins, M.D., M.P.H.

Element Scientist, Exploration Medical Capability

The University of Texas Medical Branch

NASA/Johnson Space Center Bioastronautics Contract

Anil S Menon, M.D., M.S., M.P.H.

Physician-Scientist, Exploration Medical Capability

The University of Texas Medical Branch

NASA/Johnson Space Center Bioastronautics Contract

August 2012
Available from:

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This report is also available in electronic form at http://techreports.larc.nasa.gov/cgi-bin/NTRS
TABLE OF CONTENTS

1. INTRODUCTION.....................................................................................................................1

2. METHODS................................................................................................................................2

3. RESULTS ..................................................................................................................................3

3.1 Anaphylaxis ..............................................................................................................................3

3.2 Intra-abdominal Infections........................................................................................................4

3.2.1 Appendicitis............................................................................................................................4

3.2.2 Diverticulitis ..........................................................................................................................6

3.2.3 Cholelithiasis.........................................................................................................................6

3.3 Skin Lacerations........................................................................................................................7

3.4 Behavioral Emergencies ...........................................................................................................8

4. DISCUSSION............................................................................................................................9

4.1 Anaphylaxis ..............................................................................................................................9

4.2 Intra-abdominal Infections......................................................................................................10

4.3 Skin Lacerations......................................................................................................................11

4.4 Behavioral Emergencies .........................................................................................................11

5. CONCLUSIONS .....................................................................................................................12

6. ACKNOWLEDGMENTS ......................................................................................................12

7. REFERENCES........................................................................................................................13
ACRONYMS

CRP C-reactive protein

CMO crew medical officer

EMT Emergency Medical Technician

EVA extravehicular activity

ExMC Exploration Medical Capability

HRP Human Research Project

ISS International Space Station

NOLS National Outdoor Leadership School

NEA Near Earth Asteroid

SBO small bowel obstruction

SMEMCL Space Medicine Exploration Medical Conditions List

WBC white blood cell 
1

1. INTRODUCTION

As space exploration is directed towards destinations beyond low-Earth orbit to more distant 

objectives, such as exploring a Near Earth Asteroid (NEA) or Mars, the consequent new set of 

medical risks will drive requirements for new capabilities and more resources to ensure crew 

health. The Space Medicine Exploration Medical Conditions List (SMEMCL) has been 

developed by the Exploration Medical Capability (ExMC) element of the Human Research 

Program (HRP) to address the risk of ―unacceptable health and mission outcomes due to 

limitations of in-flight medical capabilities‖.1 It itemizes 85 evidence-based clinical 

requirements for eight different mission profiles and identifies conditions warranting further 

research and technology development. These eight Design Reference Missions are: 

1. Orion to International Space Station (ISS) Transfer: 4 crewmembers (3 males, 1 female), 

3 days, no extravehicular activities (EVAs).

2. Lunar Sortie: 4 crewmembers (3 males, 1 female), 14 days, 4 EVAs/crewmember.

3. Lunar Outpost: 4 crewmembers (3 males, 1 female), 6 months, 90 EVAs/crewmember.

4. ISS Contingency Return: Illness or injury occurring on the ISS, which necessitates

contingency return from the ISS back to Earth, and requires en route medical care.

5. Lunar Sortie Contingency Return: Illness or injury occurring during a Lunar Sortie

mission, which necessitates a contingency return from the Lunar surface back to Earth 

and requires en route medical care.

6. Lunar Outpost Contingency Return: Illness or injury occurring during a Lunar Outpost

mission, which necessitates a contingency return from the Lunar surface back to Earth 

and requires en route medical care.

7. 144-Hour Depressurization Return: Illness or injury occurring during a contingency

return from a Lunar mission, assuming a depressurized cabin and crewmembers in full

pressurized suits for up to 144 hours.

8. NEA: 3 crewmembers (2 males, 1 female), 395 days, 30 EVAs/crewmember. 

Each condition is given a clinical priority for each mission profile as follows:

 2 – Shall: The condition must be addressed by the medical system.

 1 – Should: If resources are available, it is desirable for the condition to be addressed by 

the medical system.

 0 – Not Addressed: The condition will not be addressed by the medical system.

Four medical conditions from the SMEMCL—intra-abdominal infections, skin lacerations, 

anaphylaxis, and behavioral emergencies—were selected by the author as a starting point for 

analyzing all the conditions on the SMEMCL. A systematic literature review was performed to 

understand how these conditions are treated in austere, limited-resource, space-analog 

environments. In this paper, such austere environments refer to high-altitude and mountain 

environments, submarines, military deployments, Antarctica, isolated wilderness environments, 

in-flight environments, and remote, resource-poor, rural environments. These austere 

environments serve as analogs to spaceflight because of their shared characteristics such as 

limited medical resources, delay in communication, confined living quarters, difficulty with 

resupply, variable time to evacuation. Treatment of these four medical conditions in austere, 
2

limited-resource environments provides insight into medical equipment and training 

requirements for exploration-class missions.

2. METHODS

For the purposes of this publication, long-duration, exploration conditions were considered using 

the NEA mission profile. Only four conditions were chosen to initiate an analysis which was 

smaller in scale than considering every condition on the SMEMCL. Higher priority conditions 

were selected, which were deemed ―shall‖ address on the SMEMCL: anaphylaxis, intraabdominal infections, skin lacerations, and behavioral emergency. A more thorough follow-up 

analysis would consider the remaining conditions on the SMEMCL.

Literature searches were performed using keywords in PubMed, Scopus, Cinahl, National 

Technical Reports Library, and PsychINFO. Keyword searches were as follows:

1) (antarctic*[ti] OR polar[ti] OR resource[ti] OR arctic[ti] OR astronaut*[ti] OR 

wilderness[ti] OR submarine*[ti] OR "Antarctic Regions"[Mesh] OR 

"Astronauts"[Mesh] OR "Space Flight"[Mesh] OR "United States National Aeronautics 

and Space Administration"[Mesh] OR mountaineering[mesh] OR altitude[mesh] OR 

wilderness medicine[mesh] OR wilderness[mesh] OR "Arctic Regions"[Mesh] OR "naval 

Medicine"[Mesh] OR "developing countries"[mesh] OR "poverty"[mesh]) AND 

(anaphyla*[ti] OR "anaphylaxis"[mesh])

2) (antarctic*[ti] OR polar[ti] OR resource[ti] OR arctic[ti] OR astronaut*[ti] OR 

wilderness[ti] OR submarine*[ti] OR "Antarctic Regions"[Mesh] OR 

"Astronauts"[Mesh] OR "Space Flight"[Mesh] OR "United States National Aeronautics 

and Space Administration"[Mesh] OR mountaineering[mesh] OR altitude[mesh] OR 

wilderness medicine[mesh] OR wilderness[mesh] OR "Arctic Regions"[Mesh] OR "naval 

Medicine"[Mesh] OR "developing countries"[mesh] OR "poverty"[mesh]) AND 

(emergen*[tiab]

3) OR acute[tiab] OR "First Aid"[Mesh] OR "Emergency Treatment"[Mesh] OR 

"Triage"[Mesh]) AND (peritonitis[tiab] OR appendicitis[tiab] OR "intra-abdominal 

infection"[tiab] OR "intra-abdominal infections"[tiab] OR "cholecystitis"[mesh] OR 

"Gastroenteritis"[Mesh] OR "Peritonitis"[Mesh] OR (("Bacterial Infections and 

Mycoses"[Mesh] OR "Virus Diseases"[Mesh]) AND "Abdomen"[Mesh]))

4) (antarctic*[ti] OR polar[ti] OR resource[ti] OR arctic[ti] OR astronaut*[ti] OR 

wilderness[ti] OR submarine*[ti] OR "Antarctic Regions"[Mesh] OR 

"Astronauts"[Mesh] OR "Space Flight"[Mesh] OR "United States National Aeronautics 

and Space Administration"[Mesh] OR mountaineering[mesh] OR altitude[mesh] OR 

wilderness medicine[mesh] OR wilderness[mesh] OR "Arctic Regions"[Mesh] OR "naval

Medicine"[Mesh] OR "developing countries"[mesh] OR "poverty"[mesh]) AND 

(sutures[mesh] OR tissue adhesives[mesh] OR lacerat*[ti] OR "lacerations"[mesh] OR 

bandages[mesh] OR sutur*[ti] OR dermabond[ti] OR "steri-strip"[ti] OR "steristrip"[ti]) 
3

5) (antarctic*[ti] OR polar[ti] OR resource[ti] OR arctic[ti] OR astronaut*[ti] OR 

wilderness[ti] OR submarine*[ti] OR "Antarctic Regions"[Mesh] OR 

"Astronauts"[Mesh] OR "Space Flight"[Mesh] OR "United States National Aeronautics 

and Space Administration"[Mesh] OR mountaineering[mesh] OR altitude[mesh] OR 

wilderness medicine[mesh] OR wilderness[mesh] OR "Arctic Regions"[Mesh] OR "naval 

Medicine"[Mesh] OR "developing countries"[mesh] OR "poverty"[mesh]) AND 

(suicid*[ti] OR homicid* OR psychosis[ti] OR psychotic[ti] OR "Suicide"[Mesh] OR 

"Homicide"[Mesh] OR "Psychotic Disorders"[Mesh] OR "Panic Disorder"[Mesh]) AND 

(emergen*[tiab] OR acute[tiab] OR "First Aid"[Mesh] OR "Emergency 

Treatment"[Mesh] OR "Triage"[Mesh])

In the absence of comprehensive clinical research, such as trials or cohort studies, secondary 

literature such as systematic reviews and expert opinion such as clinical guidelines were used. 

Austere environments—described previously—were analyzed in regards to their similarity to 

spaceflight.

3. RESULTS

3.1 Anaphylaxis

The first condition selected from the SMEMCL was anaphylaxis. Anaphylaxis is an acute, lifethreatening, multi-organ response to an allergen that results in symptoms such as difficulty 

breathing and low blood pressure. The lifetime prevalence of anaphylaxis is estimated to be 2% 

to 4%.2 Foods and medications cause most identifiable cases of anaphylaxis. Frequent food 

triggers in U.S. populations include peanuts, tree nuts, and shellfish;3drugs such as beta-lactams, 

neuromuscular blocking agents, fluoroquinolones, and monoclonal antibodies are the most 

common medication triggers.4 Approximately 0.01% of cases are estimated to be idiopathic.5 

An inflammatory cascade caused by degranulation of IgE-mediated mast cells leading to 

anaphylaxis can be caused by most substances, even after repeated and uneventful exposure.6 

The anaphylactic reaction is characterized by flushing, urticaria, angioedema, wheezing, 

laryngospasm, abdominal cramps, diarrhea, hypotension, or shock.7 

In austere environments, the treatment of anaphylaxis is not well researched due to its rare 

incidence, sudden onset, and drastic course—it is not amenable to randomized control studies. 

However, available evidence and expert wilderness medicine consensus support immediate 

administration of epinephrine by both trained medical and nonmedical personnel, particularly if 

medical evacuation is hindered by harsh environments or geographical location.8

In a case-series of eight patients with known anaphylactic reactions to Hymenoptera stings, 

National Park Service rangers with up to 110 hours of Emergency Medical Technician (EMT)-

Basic training were able to administer epinephrine injections in the field with no adverse 

outcomes.9 Similarly, the National Outdoor Leadership School (NOLS) database recorded two 

cases of anaphylaxis in 20 years (2.5 million participant-days) that were administered 

epinephrine and 149 cases of acute allergic reactions (not categorized as anaphylaxis) that were 

administered antihistamines. NOLS instructors, who had no formal medical training beyond 
4

basic EMT training, administered these medications, and no deaths were reported among these 

patients.8

Arrhythmias, stroke, and myocardial infarctions have been reported as adverse effects of 

epinephrine administration for anaphylaxis.10 However, literature demonstrates that these 

reactions were in elderly patients with known cardiac disease or occurred because of medication 

overdose. A Colorado youth developed ventricular dysrhythmia and myocardial ischemia after 

receiving a tenfold increased dose by EMTs.8,11 Because of this incident, the Wilderness Medical 

Society recommends auto-injectors or prepackaged medication kits to decrease this risk.8Since 

anaphylaxis is life-threatening, there is no absolute contraindication to administering 

epinephrine.

A more common complication from epinephrine use in EpiPen (ActiveAide, Redwood Falls, 

MN) form is digital auto-injection, where the wrong end of the EpiPen is depressed and the 

finger is injected with epinephrine, potentially resulting in digital ischemia. However, a recent 

6-year retrospective cohort study of accidental digital epinephrine injections reported to 

emergency departments and local Poison Control Centers (N= 127) demonstrated very few local 

and systemic effects; most cases required observation with complete resolution of symptoms.

12

 

No lasting symptoms were observed in the 23% that did receive treatment with vasodilators, 

suggesting that auto-injection of epinephrine is safe for spaceflight.

In summary, the mainstay of treatment for true anaphylaxis is rapid recognition of symptoms and 

administration of epinephrine and other synergistic medications, most of which are already 

included in current medical kits for other conditions: antihistamines, albuterol, intravenous 

fluids, and steroids. Wilderness literature has shown that anaphylaxis prevalence to be 0.01% to 

2% depending on etiology.7 Although rare, the consequences of untreated anaphylaxis are lifethreatening. 

3.2 Intra-abdominal Infections

The second condition selected from the SMEMCL was intra-abdominal infections which are

further delineated into appendicitis, diverticulitis, and cholecystitis.

3.2.1 Appendicitis

Appendicitis is the most commonly documented surgical condition in austere environments as 

shown in submarine and Antarctic populations.13 The lifetime prevalence of appendicitis in the 

United States has been estimated at 8.6% for men and 6.7% for women.14 This incidence 

decreases with age. Increased incidence was observed in Australian polar expeditions, which was 

hypothesized to be linked to immunosuppression.15 Although astronauts are predicted to have a 

low likelihood of developing appendicitis based on an average age of 45, spaceflight 

immunosuppression might increase their risk.13,16-18

When surgery is not available in an austere environment, appendicitis may be medically 

managed with antibiotics, analgesics, and intravenous fluids. The documented success rate of 

medical management of appendicitis ranges between 88% to 100%,19 even in cases with 
5

perforated viscera; however, the highest documented success rates of medical management were 

achieved when therapy was initiated within 6 hours of suspected diagnosis.20 The recurrence 

rates after medical management of appendicitis in these studies were 5% to 38% within 17 

months.19 

Several more studies have reviewed medical management of appendicitis, which provides input 

into alternate treatment strategies in austere environments. Sakorafas posited that medical 

management is appropriate in many cases of suspected appendicitis without signs of frank 

peritonitis, and stated that this approach would be best applied in areas with poor health services 

or lacking operative capabilities.21 In a 2006 prospective, multicenter, randomized control trial 

in which patients were randomized to surgical versus medical treatment, only 12% of patients 

ultimately required operation in the first 24 hours; the incidence of perforation was 5% in both 

groups, and the recurrence risk was 3% to 25%.22 A separate study reported a recurrence rate of 

37%. 21,22 However, in the event of recurrence, Styrud showed in a prospective, multicenter, 

randomized control trial that antibiotic therapy could be used a second time. Those who 

presented with late recurrence were likely to have a mild clinical course.23

A former report shows anesthesia and surgical morbidity associated with emergency 

appendectomy is sevenfold that of non-operative management for age- and gender-matched 

populations.21 In selecting appropriate candidates for medical management, early, mild disease 

has been shown to respond best to antibiotic therapy. Antibiotic therapy is still the 

recommended management in cases of complicated appendicitis involving phlegmon or abscess 

formation.22 

Though white blood cell (WBC) count and C-reactive protein (CRP) are often used as markers of 

infection, WBC count is not a reliable diagnostic tool, particularly if an individual is 

immunosuppressed. Repeated CRPs may be used to monitor severity of infection, although this 

may not be reliable in perforated or gangrenous appendix.24 

Prophylactic appendectomies, which remove a normal appendix to prevent possible appendicitis

before an expedition, have been proposed in an effort to mitigate the risk of appendicitis. The 

Antarctic research expeditions of Russia, China, Chile, Argentina, France, and the United 

Kingdom have intermittently required prophylactic appendectomies of their participants. 

Australian program Antarctic expeditions have consistently required Australian physicians 

wintering over in Antarctica to undergo prophylactic appendectomies since 1950. Other project 

members have inconsistently been required to undergo appendectomy. A non-physician project 

member did develop appendicitis requiring evacuation but was not evacuated, thereby resulting 

in his death. Since that occurrence, the Australian program began to require prophylactic 

appendectomies, which reduced the incidence of appendicitis from 43/1,000,000 person-days to 

4.07/1,000,000 person-days.25 It is possible that the incidence of appendicitis after appendectomy 

resulted from stump appendicitis, but the reports are not clear enough to delineate the exact cause 

of their abdominal pain. 

Small bowel obstruction (SBO) is the most concerning complication associated with 

appendectomies. In the urban setting, open appendectomies have been reported as being 

associated with a 1.5% prevalence of SBO up to 15 years following initial surgery, and requiring 
6

surgical intervention.26 Lifetime prevalence is expected to be lower after prophylactic 

appendectomies because the appendix is not inflamed. A recent review of risk factors for postlaparotomy adhesions showed the rate of adhesion-related re-admissions from 4,445 

laparoscopic appendectomies to be 1.3%,27 which was relatively unchanged compared to the 

open appendectomy SBO incidence of 1.4%. It is unclear whether these cases ultimately 

required surgical intervention because adhesion-related re-admission was the end-point of the 

studies reviewed, not surgical intervention. Furthermore, no data on the complication rates of 

operative appendectomies in analog environments were available.

3.2.2. Diverticulitis

Diverticulitis is more common in the fourth to fifth decade of life, affecting one-third of the 

United States population over age 45.7 Complicated diverticulitis is defined as diverticular 

disease involving abscess formation or perforated viscus. In the past, this was often treated 

surgically, either with partial colonic resection or with percutaneous drainage of the abscess. 

Recent studies have shown good results with conservative management.28 

In the absence of data from analog environments, all available literature was reviewed. In a

single-institution, retrospective review of patients admitted for diverticulitis, 136 patients over a 

13-year period were found to have perforated viscus and the vast majority of these (91%) were 

successfully managed non-operatively—even those with severe disease (defined by moderate to 

large free air or large abscesses).28 Although this study did have patients that ultimately 

underwent elective resection for their diverticular disease, this was less than half (48%) of the 

study group. A greater than 90% success rate of non-operative intervention for acute diverticular 

disease has been cited in other studies as well and further stratified into 95% non-operative 

success rate in mild disease29 and 93% success rate in 511 patients for diverticular disease 

without abscess or perforation.30 

In a survey of 379 Dutch gastroenterologists and surgeons, 90% reported that they manage mild 

disease with simple bowel rest and no antibiotics,31 whereas U.S. cases have been shown to 

successfully be treated only with single-agent, oral antibiotic therapy.32 A recent systematic 

review of management of diverticulitis concluded that the heterogeneity of patients with colonic 

diverticular disease dictated that treatment should be tailored on an individual basis.33

3.2.3. Cholelithiasis

In the United States, acute cholecystitis is traditionally treated with early laparoscopic 

cholecystectomy. A recent review of 7,103 laparoscopic cholecystectomies showed the 

postoperative incidence of SBO to be 0.2% up to 5 years following surgery.27 However, some 

literature exists to support delayed operative intervention, as it is widely practiced outside the 

United States. In a retrospective chart review of nine Japanese hospitals, delayed laparoscopic 

cholecystectomy (defined as greater than 7 days from initial presentation) had a higher rate of 

intra-operative complications compared to open cholecystectomy but overall similar postoperative complication rates.34

 
7

The safety of performing laparoscopic or open cholecystectomy in an austere environment was 

investigated in a recent retrospective study performed in Afghanistan35. The technical 

complication rate of laparoscopic cholecystectomy was 3.9%, higher than those reported in other 

developing and developed countries; none of the major operative complications (three bile leaks 

and one duodenal perforation) were detected intra-operatively, requiring further interventions 

after the initial surgery.35 This study was limited by unequal treatment groups (102 patients 

received laparoscopic cholecystectomy whereas 35 received open cholecystectomy) and 

suboptimal surgical conditions related to operator experience, peri-operative resources (e.g., 

endoscopic retrograde cholangiopancreatography), and physical environment. Good outcomes 

with laparoscopic compared to open cholecystectomy were reported in a separate prospective, 

nonrandomized, study of 45 patients in resource-poor Yemen; however, these procedures were 

performed by experienced general surgeons.36

An alternative to laparoscopic cholecystectomy practiced in the West Indies is mini-laparotomy 

cholecystectomy, which has been reported to have a conversion rate of only 4% in a study of 476 

patients.37 The mean incision length was 4.8 cm with a mean operating time of 31 minutes, and 

wound infection was the only postoperative complication, seen in less than 10% of patients. 

However, a randomized trial comparing mini-laparotomy to open cholecystectomy in 60 patients 

showed no significant difference in complications between the two options.

38 This study did not 

have many subjects and was not performed in an austere environment.

3.3 Skin Lacerations

The third condition selected was skin lacerations, which may coexist with other forms of soft 

tissue trauma, underlying occult infection, or may be complicated by form, depth, or joint space 

involvement. In an effort to simplify definitions, only isolated skin lacerations are considered in 

this section.

One of primary end-goals of any wound management is avoiding infection. Assuming any of the 

coexisting injuries are absent, the management of lacerations necessitates hemorrhage control, 

wound exploration, anesthesia, irrigation, debridement, and, if indicated, wound closure, 

antibiotic administration, and tetanus prophylaxis.

In austere environments, lacerations rarely require wound closure7and sometimes may be 

contraindicated based on the degree of contamination and inability to reliably irrigate the wound. 

When closure is indicated, anesthesia will usually be needed.

Irrigation fluid type in resource-poor environments depends on local availability. Studies have 

shown that boiled, filtered fresh water,39 or tap water is as effective as normal saline in reducing 

bacterial counts through irrigation—an important component of infection prevention.40,41 At 

least 500 ml of irrigation fluid should be used at a minimum of 5 to 8 psi.39 In both irrigation 

and debridement, the goal in austere environments is to remove any visible foreign objects and 

devitalized tissue prior to repair.

While suturing is easily performed by medically trained personnel and sutured laceration repair 

has effectively been performed in parabolic flights,13,42 needle safety and body substance 
8

isolation may present a challenge. If sutured closure is to be undertaken, a study with 50 

subjects in a rural Canadian practice showed that full sterile technique versus surgically clean but 

non-sterile technique had no difference in healing rate or post-closure complications, including 

infection.43

The safest management strategy for lacerations in the wilderness is open management or closure 

with non-suture alternatives and appropriate prevention against infection.7 Tape and Steri-Strips

(3M, Minneapolis, MN) have been shown to be rapid, safe, easy, and as effective in the 

appropriate wound as sutures or staples.7 In fact, in a prospective analysis of 147 contaminated 

wounds in the West Indies that were closed with Steri-Strips and without any cleaning, the sepsis 

rate was 1.4%, with an overall complication rate of 2.7%.44 Antarctic expedition populations 

have also published success in using glues such as cyanoacrylates for closure of cold-induced 

fingertip fissures with improved finger function and faster resolution of symptoms.45

The Wilderness Medical Society recommends prophylactic antibiotics for the following 

indications: 

 Significantly contaminated wounds requiring extensive cleaning and debridement 

(especially in immunosuppressed patients)

 Violation of cartilage, joint spaces, tendon, or bone

 Crush-mechanism wounds with a high potential for devitalization

 Mammalian bites

Five days of amoxicillin-clavulanate, second- or third-generation cephalosporins, 

fluoroquinolones, penicillinase-resistant penicillins, or tetracyclines are appropriate.39

In summary, to prevent wound infection, proper skin laceration management does not require 

specific irrigation fluid, but does require adequate irrigation at pressure to effectively reduce the 

risk of infection. With regards to wound closure, sterile technique has not been shown in austere 

analogs to be any more effective in reducing infection rates than non-sterile technique; nonsuturable wound management is an acceptable alternative to sutures in austere environments. 

3.4 Behavioral Emergencies

Isolation and behavioral problems have long been reported as the largest medical issue in 

Antarctic expeditions.46 Given that this analog is frequently used to predict exploration missionclass outcomes, it deserves significant attention. For the purposes of this discussion, behavioral 

emergencies are defined as suicidal or homicidal ideation, psychosis, and panic attack. Anxiety 

and depression are treated as a separate condition in the SMEMCL.

A case of psychosis in the Antarctic was reported in 1957 and was an impetus to extensively 

review U.S. Navy selection criteria for polar expeditions.47 While documentation of this incident 

was sparse, references suggested that resources were inadequate for evacuation.48 

As a result of similar psychological crises in early polar expeditions, efforts were directed toward 

prevention via ―select out‖ criteria in subsequent endeavors, which drove case reports from the 

acute cases to chronic cases. Given the extensive efforts by the Navy and subsequent expedition 
9

programs to select out any disqualifying conditions, the dearth of acute behavioral emergencies 

seems to be a reflection of the effectiveness of preventive medicine.

The concept of developing shared psychotic disorder (folie-a-deux) has been raised during a 

review of case reports, but the precise etiology of the disorder remains unclear despite 

documentation dating back to 1877.49 However, prolonged isolation remained the principleinciting factor. 

In the event that a true behavioral emergency would occur, the Wilderness Medical Society’s 

category 1B recommendation regarding stress reactions focused attention on the affected team 

member and encouraged verbalization of their emotions to an attentive caregiver who would 

provide feedback and empower the patient to take an active role in their own care.39

Benzodiazepines, which are usually used for anxiety and panic disorders, have been successful in 

austere environments.

50

 Psychotic reactions might also be temporized with benzodiazepines. 

For acute psychotic events, haloperidol is safe and effective. In the event that medications are 

ineffective or not adequate, physical restraints can be used as adjuncts for patient and caregiver 

safety.

4. DISCUSSION

Anaphylaxis, intra-abdominal infections, skin lacerations, and behavioral emergencies are four 

conditions in the SMEMCL that were analyzed for treatment strategies in austere environments. 

Several limitations were encountered in this review. First, there is a dearth of systematic reviews 

on which to base clinical guidelines other than the Wilderness Medical Society’s clinical 

guidelines, which suggest evacuation for definitive care. Next, much of the primary literature 

relies on small sample sizes, limiting statistical certainty from which to draw conclusions. 

Finally, while studies in austere environments such as Nepal or Africa exist, additional 

confounding factors may affect outcomes, such as socioeconomic status, chronic conditions, and 

other social aspects impacting the health of subjects involved, rendering these studies difficult to 

use for the purposes of the SMEMCL. Despite these limitations, those insights relevant to 

exploration-class missions are detailed below.

4.1 Anaphylaxis

Anaphylaxis occurs terrestrially at a lifetime prevalence of 2% to 4%, but in the context of 

spaceflight might increase due to immunologic effects or decrease due to good crewmember 

health. As discussed in the results section, allergy screening for common triggers can aid in 

prevention by removing concerning substances from the mission manifest. Preventive action can 

reduce the incidence further by ground-testing medications. Evidence from austere environments 

indicates that treatment can be administered safely by non-medically trained personnel. A short 

training session on EpiPen use should be sufficient given the infrequent and minor complications 

associated with its use. In addition, the mass of epinephrine is small and can be used for other 

medical purposes, so it would be prudent to prepare for this condition on exploration missions in 

order to avoid potential loss of crew life.
10

4.2. Intra-abdominal Infections

Intra-abdominal infections occurring in austere environments without significant surgical support 

are best treated by evacuation to a definitive care facility. In rare cases, remote surgery has been 

attempted but previously cited literature supports non-operative treatment with antibiotics as a 

temporizing measure. 

Before treatment is even initiated, diagnosis may be complicated in spaceflight. For example, 

microgravity shifts intra-abdominal contents, which could potentially alter classic physical 

findings of appendicitis such as tenderness at McBurney’s point. Also, acute, complicated 

diverticulitis would be rare in-flight, but with constipation being a known medical condition on 

orbit,1diverticulitis might be increasingly likely during exploration missions. Newer imaging 

modalities such as ultrasound could be used to mitigate difficulties with diagnoses. As discussed 

in the results section, early diagnosis improves the efficacy of treatment with antibiotics.

Current difficulties associated with performing surgery in microgravity support nonsurgical 

approaches to intra-abdominal infections. Whereas dissections and surgeries were performed on 

animal models during Neurolab,

13 human surgery during exploration missions would be 

complicated by mass restrictions, hardware certification, expertise, and adequate time in the 

training to maintain proficiency in a variety of potential surgical procedures. 

If surgery is not going to be performed, then medical management will reduce the impact of an 

intra-abdominal infection. Non-operative management of appendicitis is already being used in 

austere environments with a success rate of 88% to 100%. Antibiotics should be carried in 

sufficient quantities to also treat a recurrence. Though non-operative management of 

cholecystitis may be a bridge to definitive management, cholecystectomy is currently required.

Further research into non-operative management of cholecystectomy is necessary to better 

characterize that risk. Medical management of SBOs is possible, effective, and has a lower 

morbidity than the other two infections.

An important adjunct to non-operative management would be enhanced prevention to reduce the 

likelihood of developing an intra-abdominal infection. Prevention of intra-abdominal infections 

comes in two forms: screening and prophylactic surgery. Individuals with preexisting 

cholelithiasis and diverticular disease will be screened during astronaut selection and preflight

exams. Though prophylactic surgery is rarely performed prior to entering austere environments,

it might be more important before exploration missions. Long-duration spaceflight differs from 

many austere environments because evacuation might be impossible and, thus, might necessitate 

prophylactic surgery.

Prophylactic surgeries such as appendectomy or cholecystectomy increase the risk of SBO. As 

previously mentioned by Barabas, the risk of SBO after laparoscopic or open appendectomy is 

1.4% to 1.5%. His study and similar studies found this risk to fall within a year of surgery. A 5-
11

year prospective study showed the mean time to post-appendectomy SBO was 1.1 years.

51 The 

rates of SBO following appendectomy are lower for a normal appendix compared to an inflamed 

appendix, which is 5.9%, due to exploration of the abdomen.

51,52

 This evidence supports 

prophylactic appendectomy followed by a 2-year waiting period in order to reduce risk of inflight appendicitis. Prophylactic cholecystectomy is rarely performed and not well characterized 

in medical literature. Further risk stratification is necessary before recommending prophylactic 

cholecystectomy.

4.3 Skin Lacerations

Literature that has been reviewed focused on wound healing by limiting the potential for 

infection and wound repair techniques to enhance closure. Immunosuppression during 

spaceflight requires more research but might increase the risk of infection.

18

 Since wound 

irrigation is the primary method of reducing infection in austere environments and spaceflight 

might limit irrigation capabilities, prophylactic antibiotics may be indicated. Topical and oral

antibiotics taken as a prophylactic might reduce this risk even though they are not a standard of 

care on the ground. 

Wound infection might further be reduced by utilizing non-suture wound closure. The role of 

tissue adhesives and Steri-Strips can be expanded in spaceflight. Tissue adhesives have 

successfully been applied in microgravity.18 In the event of a laceration involving the vermilion 

border of the lip or involving critical components of the eyelids, for which plastic surgery or 

ophthalmology consultant services are typically requested, open management or Steri-Strips can 

be considered53 (telemedicine guidance is another alternative for complicated repairs). Also, as 

described in the results section, delayed primary closure can help mitigate wound infection in the 

absence of adequate irrigation and is currently recommended by the Wilderness Medical Society 

as a potential treatment.

4.4 Behavioral Emergencies

Due to the extensive psychiatric and psychological screening during astronaut selection, it is rare 

that a psychiatric event such as anxiety or panic disorder would surface based on genetic 

predisposition or preexisting psychiatric diagnosis.54 The risk of psychiatric emergencies 

appears to be well-controlled with preventive measures and screening criteria in spaceflight.

Long-duration spaceflight might trigger behavioral emergencies at a higher frequency than 

current mission profiles. Crew composition should also be carefully considered. For example, 

men may be much more likely to be violent than women,

7 which is important considering an 

exploration mission with a higher percentage of males. Standard of care disorders is followed in 

austere environments using benzodiazepines and haldoperidol. In spaceflight, this can be used 

and supplemented with supportive care and counseling from teammates or remotely. In addition, 

crewmembers might be trained on psychiatric disorders and offering acute support in the event of 

crisis.
12

5. CONCLUSIONS

The four conditions from the SMEMCL that were reviewed as a starting point for understanding 

treatment approaches in austere environments and research highlights are summarized below.

Anaphylaxis:

 A terrestrial treatment strategy of epinephrine, diphenhydramine, and steroid is 

recommended given mass, ground-based incidence, and potential mission impact of 

disease.

 Epinephrine can be safely administered by non-medical crewmembers with minimal 

training.

Intra-abdominal infection:

 Non-operative management in-flight can substitute for surgery in cases of appendicitis, 

diverticulitis, cholelithiasis, and bowel obstruction. However, cholecystitis is least likely 

to improve without surgery.

 Current literature suggests that prophylactic surgery is slightly safer than non-operative 

management in-flight, especially 2 years after the surgery. More research is needed to 

define the lifetime incidence of SBO after surgery and non-operative management of 

cholecystitis.

Skin lacerations:

 If copious wound irrigation is not possible in-flight, then topical and oral antibiotics 

should be considered as a prophylactic measure.

 The role of tissue adhesives can be expanded to include wound closure beyond the scope 

of ground-based lacerations.

 Delayed primary closure should be considered in complicated and contaminated wounds.

Behavioral emergencies:

 Benzodiazepines and haloperidol should continue to be supplied in medical kits for 

psychiatric disorders.

 Crewmember training can include acute management and assistance for psychiatric crisis.

6. ACKNOWLEDGMENTS

Special thanks to Paul Auerbach, MD, MS, who served as technical consultant on this project, 

and Chris Stave for his expertise in effective literature searches.
13

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August 2012 NASA Technical Memorandum

4. TITLE AND SUBTITLE 5. FUNDING NUMBERS

Anaphylaxis, Intra-abdominal Infections, Skin Lacerations, and Behavioral Emergencies: A 

Literature Review of Austere Analogs for a Near Earth Asteroid Mission 

6. AUTHOR(S)

Natacha G. Chough, Sharmi Watkins, Anil S. Menon

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REPORT NUMBERS

Lyndon B. Johnson Space Center

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TM-2012-217362

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13. ABSTRACT (Maximum 200 words)

As space exploration is directed towards destinations beyond low-Earth orbit, the consequent new set of medical risks will drive 

requirements for new capabilities and more resources to ensure crew health. The Space Medicine Exploration Medical Conditions List 

(SMEMCL), developed by the Exploration Medical Capability element of the Human Research Program, addresses the risk of 

“unacceptable health and mission outcomes due to limitations of in-flight medical capabilities”. It itemizes 85 evidence-based clinical 

requirements for eight different mission profiles and identifies conditions warranting further research and technology development. 

Each condition is given a clinical priority for each mission profile. Four conditions—intra-abdominal infections, skin lacerations, 

anaphylaxis, and behavioral emergencies—were selected as a starting point for analysis. A systematic literature review was performed 

to understand how these conditions are treated in austere, limited-resource, space-analog environments (i.e., high-altitude and 

mountain environments, submarines, military deployments, Antarctica, isolated wilderness environments, in-flight environments, and 

remote, resource-poor, rural environments). These environments serve as analogs to spaceflight because of their shared characteristics 

(limited medical resources, delay in communication, confined living quarters, difficulty with resupply, variable time to evacuation). 

Treatment of these four medical conditions in austere environments provides insight into medical equipment and training requirements 

for exploration-class missions.

14. SUBJECT TERMS 15. NUMBER OF 

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16. PRICE CODE

long duration space flight; near Earth asteroid; medical science; health; analogs

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