Embalming 2 Chapter 24: Selected Conditions

*What specific solution strength is recommended to begin with on bodies that have had renal failure?*

-2%

*What fluid index is recommended for mixing arterial solution when a body has had renal failure?*

-30-35

*These type of infections will predispose a body to purge?*

-Bloodstream

*During what part of the embalming process does brain purge usually occur?*

-During arterial injection

*Where does C. Perfringens normally inhabit?*

-GI tract

*What can you do to help prevent subcutaneous emphysema from entering the head?*

-Inject stronger solution. ---> This creates enough resistance in the tissues to prevent distension if gasses wanna relocate into the facial tissues.

*What should you apply to cotton before packing the throat?*

-Massage cream or Autopsy Gel

*What is the recommended injection type for bodies with subcutaneous emphysema?*

-Restricted Cervical Injection

What vessel should you use for drainage on a body with varicose veins?

-Right internal jugular vein

*clostridium perfringens*

-Tissue Gas

*Visceral Expansion*

-When bodies have been dead for several hours and arterial solution is injected too fast, the hollow visceral organs (intestinal tract) tend expand. ---> pressure on stomach walls = stomach purge. ---> pressure on diaphragm squeezing lungs = lung purge.

When is the best time to try and remove gas caused by subcutaneous emphysema?

-after embalming

*When does gas gangrene usually occur?*

-after severe trauma: ---> ex> car accidents, gunshots where the wound is contaminated.

*What is the only effective way to release any gas from the tissues?*

-lance & channel tissues

*What kind of purge is caused by visceral expansion?*

-stomach & possibly lung

4 types of bodies is it recommended to inject additional cavity fluid to prevent postembalming purge:

1.) obesity, 2.) ascites, 3.) recent abdominal surgery, 4.) decomposition - reaspirate/ inject bodies that have been shipped in.

CONDITIONS PREDISPOSING TO TISSUE GAS:

1.) recent abdominal surgery. 2.) gangrene present at TOD. 3.) intestinal ulcerations & perforations. 4.) contaminated skin wounds/punctures. 5.) intestinal obstruction or hemorrhage. 6.) poor embalming. 7.) contact with contaminated instruments.

In the treatment of a body with true tissue gas, what injection technique should be employed in order to ensure good preservation (use a strong preservative obv.)

6-point. ---> incisions can remain open for several hours in order to allow gas to escape.

Candidiasis may affect what and may cause what?

Affects the: ---> oral mucosa. ---> pharynx. ---> skin, nails, vagina. ---> respiratory tract. May cause: ---> lesions on the skin, nails and mucosa. ---> can affect the respiratory tract (esophageal and bronchopulmonary) ---> Candidal endocarditis can result from IV drug users or patients who have had cardiac surgery. ---> oropharyngeal candidiasis is a specific complication of AIDS (causes lesions and GI infections).

If the legs of an obese case are not recieving arterial solution, what vessels should be raised?

THE EXTERNAL ILLIACS along the inguinal ligament. ---> (more superficial than femorals).

-the agent that causes thrush

*Candida albicans*

fungal infections that may have been present as an antemortem condition or occured as the result of a postmortem invasion. ---> fungi may be saprophytic (feed off dead material) or parasitic (feed off living material). -EX> Candidiasis (moniliasis) -EX> Aspergillosis. -EX> Phycomycosis. -EX> Histoplasmosis

*MYCOTIC INFECTIONS*

When arterial solution is present in purge during arterial injection and drainage has stopped, what is happening and what needs to be done?

- A major fluid loss is occurring and distribution is not taking place. ---> Evaluate the body and use sectional arterial injection where needed.

How does gas cause purge

- Gas—Gas in the abdominal cavity or in the hollow intestinal tract can create sufficient pressure on the stomach to force the contents of the stomach through the mouth or the nose. ---> this pressure may also push on diagphram pushing on the lungs. Causes: - Early decomp gasses. - true tissue gas

Treatment for purge that occurs from the mouth or the nose after the body has been dressed and casketed:

- Remove trocar button and pass trocar into the viscera to relieve pressure. - re-aspirate + re-inject.

How to treat post-emb. anal purge?

- force as much of the purge material from the body as possible. - Then pack the rectum with the cotton saturated with a phenol solution, autopsy gel, or cavity fluid.

Signs that a body has been affected by renal failure:

- sallow color. ---> resulting from urochrome buildup. -uremic puritis: ---> scratch marks on the extremeties. -increase in amount of urea, uric acid, ammonia, and creatine. ---> ammonia and urea can be detected by their odor. -acidosis. ----> increases lactic acid in the muscle tissues. -----> Acid pH requires buffers in order to allow HCHO to act on an alkaline env. -edema. ---> retention of sodium by the kideys leads to increased water retention and thus hydrolysis. -anemia. -GI bleed. ----> can be seen in anal purge. -lack of firming. ---> caused by excess nitrogenous wastes in the tissues which neutralizes HCHO.

*To prevent post-embalming purge, thoroughly aspirate the body cavities & inject with at least this much cavity fluid?*

-16 oz per cavity

*What gas is first seen in eyelids, has no odors, no skin slip, & the amount depends on the injection time?*

-air from embalming machine

*What makes up purge from the esophageal varices?*

-blood & arterial solution

*What gas is characterized by a possible odor, skin-slip in time, color changes, & purging?*

-decomposition

*Where is true tissue gas usually formed more rapidly?*

-dependent tissues & organs

*What are the origins of gas in a deceased?*

-early decomp, -digestion of foods, -true tissue gas

*What areas are the most likely to be distended because of true tissue gas?*

-eyelids, neck, & scrotum

*Tuberculosis of the lungs, cancer, pneumonia, & bacterial infections of the lung can cause ______?*

-fluid loss through weakened cavities

*Over time, where does gas in the body move to?*

-higher body areas

*How can you relieve the pressure/distention of the abdomen if it is caused by either gas or edema?*

-inserting of a trocar into the ventral part of the abdominal cavity

*What should you do to the incisions made on a body with decomp gas, tissue gas, or gas gangrene?*

-leave them open for several hours to allow the gases to escape

*What area of the abdomen should you insert a trocar to drain ascites during injection?*

-lower left inguinal area

*What causes subcutaneous emphysema?*

-puncture or tear in the pleural sac or lung tissue causing air to escape into the tissues. ---> Frequently follows compound fracture of a rib, tracheotomy, lung surgery, or projection of an object (such as a bullet) into the pleural sac.

*What should you do to bodies that have decomp gas, gas gangrene, or tissue gas to ensure that bacterial activity has ceased?*

-reaspirate & reinject

*What areas of the body are often affected by mycotic infections?*

-skin & mucous membranes

*Pre-embalming purge usually consists of the ___________?*

-stomach contents

*Name the gas: NOT created by microbes, does not continue to intensify after death; no odor, no skin-slip, no blebs, gas can reach distal points (even toes), can created intense swelling, rises to highest body areas (face/neck)*

-subcutaneous emphysema

*What is commonly caused by a compound fracture of the rib, tracheotomy, lung surgery, or the projection of an object into the pleural sac?*

-subcutaneous emphysema

*What is the most frequently encountered type of gas?*

-subcutaneous emphysema

*2 things that are necessary for purge to occur*

-substance to purge & pressure on organs

*Crepitation*

-the noise & feeling caused by pushing on tissue where gas is present.

*What can you do while pulling the carotid artery to help prevent purge?*

-tie off or sever the trachea & esophagus

*How can you remove gas in the trunk tissues?*

-trocar after arterial injection ---> During cavity aspiration, the trocar is channeled thru the thoracic and abdominal walls. ---> scrotum can be channeled this way too.

Name the gas: very strong odor of decomp, skin-slip, skin blebs, increase in intensity & amount of gas, possible transfer of spore-forming bacterium via cutting instruments to other bodies

-true tissue gas

*What is the name for the itchy skin caused by renal failure?* ---> what is the sign of uremic pruitis?

-uremic pruritis ---> scratch marks on the skin.

-The postmortem evacuation of any substance from any external orifice of the body as a result of pressure

*PURGE*

*What should the pressure on the centrifugal machine be set at for instant tissue fixation?*

-20 psi or higher with the rate of flow valve closed

How can you remove gas in the neck and facial tissues?

-AFTER arterial emb., use trocar to channel the neck and remove gas. ---> insert thru the abdominal wall, beneath the rib cage, under the clavical to reach the neck.

*What is the danger of gas gangrene?*

-It may not be visible; may be completely internal but if the body is not sufficiently emb. the gas gangrene may show up several hours after emb.

*What vessel do you inject first when attempting instant tissue fixation of the head?*

-Left common carotid

*What should you do with brain purge during embalming?*

-Let it purge

*Urochrome*

-a buildup of what gives the sallow color to the skin of a body that has had renal failure

*What form of gas is not common today?*

-air from embalming machine

*This purge is a bloody liquid*

-esophageal varices

2 edematous conditions in which edema fills the thoracic or abdominal cavity prior to death, a great amount of pressure builds up and, on injection of arterial solution forces purge.

Ascites and hydrothorax.

1.) Orifice: ---> mouth/nose ---> anal orifice. 2.) Description: ---> color of cavity fluid. ---> blood present is brown in color. 3.) Contents: ---> cavity fluid 4.) Time: ---> postembalming.

CAVITY FLUID PURGE:

1.) Orifice: ---> Fracture in skull. ---> Nose --> fractured ethmoid/ temporal. ---> fractured ear ---> surgical openings. 2.) Description: ---> white semisolid. ---> gas. 3.) Contents: ---> brain tissue. ---> blood. ---> arterial solution. 4.) Time: ---> pre, during, postemb. 6.) Causes: ---> fracture of the skull. ---> surgical procedure. ---> trauma (bullet penetrating skull). 5.) complications: ---> Gas buildup in the cranium can distend eye/ tissues (eyelids). ---> purge from the nose = caused by a fracture to cribriform plate. ---> purge from ear can be from temporal bone fracture. 6.) TREATMENTS: ---> Let purges continue during emb.

BRAIN PURGE

1.) Orifice: ---> mouth/nose., ---> anus/ear. 2.) Description: ---> Color of arterial solution injected. 3.) Contents: ---> arterial solution. 4.) Time: ---> during emb.

EMBALMING SOLUTION PURGE:

1.) Orifice: ---> Mouth ---> Nose 2.) Description: --->bloody liquids 3.) Contents: ---> blood. ---> arterial solution. 4.) Time: ---> pre, during, postembalming.

ESOPHAGEAL VARICES (purge)

A fatal disease caused by contamination of a wound infection by a toxin-producing, spore-forming, anaerobic bacterium. --> C. perfringens is the most common clostridium bacteria responsible. ----> Bacterium builds in tissue of wounds, releasing exotoxins, fermenting muscle sugars, and creating pressure build-up by accumulated gas tearing the tissues apart. --> Generally occurs after severe trauma. --> affected tissue decomposes, blisters, and skin-slip forms on the surface. --> foul odor. --> crepitation.

GAS GANGRENE

treatment of postembing cranial purge:

Pass an infant trocar or large hypodermic needle through the surgical opening, the body fracture, or the cribriform plate. ---> To aspirate the cribiform plate, insert the needle thru the nostril. ---> Inject brain with small amount of cavity fluid.

What condition should the embalmer suspect if during and after emb. the tissues fail to respond by firming?

RENAL FAILURE ---> Up to 6 times more preservative chemical may be needed to preserve the tissues dead form the complications of renal failure.

If there appears to be a buildup of gas in the abdominal cavity, consider doing what?

Reinjection.

1.) Orifice: ---> Mouth ---> Nose 2.) Description: ---> Liquid/semi-solid. ---> coffee ground appearance (brown). ---> foul odor ---> acidic. 3.) Contents: ---> Stomach contents ---> blood. ---> arterial solution. 4.) Time: --->Pre; during; postemb. 5.) TREATMENT: ---> Nasal tube aspirator to remove purge in the throat, and nose. ---> Restricted cervical injection to allow purge to flow during injection allowing embalmer to set features and pack orifice after injection. ---> massage cream to protect skin.

STOMACH PURGE

SOURCE OF GAS: ---> Anaerobic bacteria, C perfringens. CHARACTERISTICS: ---> occurs from contaminated cases of severe trauma. --->Foul odor, infection. ---> Affected tissue decomps, blisters/skin-slip. ---> crepitation. TREATMENT: ---> Strong arterial solutions. ---> Local hyp injection of cavity fluid.

GAS GANGRENE

SOURCE OF GAS: ---> Anerobic bacteria (gas gangrene), C. perfringens. CHARACTERISTICS: ---> Very strong odor of decomp (sulfur). ---> skin-slip; skin blebs. ---> increase in intensity and amount of gas. ---> possible transfer of spore-forming bacterium via cutting instruments to other bodies. ---> Gas generally forms more rapidly/ in greater intensity within the dependent tissues and organs. --------> these areas become congested with blood (and are poorly reached by arterial fluids). ---> The gas is in larger volume than the liquid is displaces, thus tears and distends tissues. --------> Majority of distension is in the eyelids, neck, and scrotum. TREATMENT: ---> SPecial tissue gas arterial solutions (halt). ---> Localized hypo injection of cavity fluid. ---> channeling of tissues to release gasses.

TRUE TISSUE GAS

2 classifications of facial trauma

1.) Broken skin: ---> (abrasion, laceration) 2.) unbroken skin: ---> (contusion, hematoma)

what 3 types of gasses all have bacterial origins?

1.) decomp gas. 2.) tissue gas. 3.) gas gangrene

COnditions predisposing to purge:

1.) Decomposition. 2.) Long delay between death and embalming. 3.) Drowning or asphyxia. 4.) Recent abdominal, thoracic, or cranial surgery. 5.) Tissue gas. 6.) Hydrothorax or ascites. 7.) Peritonitis or bloodstream infections. 8.) Esophageal varices, ulcerations of the GI tract, or internal hemorrhages. 9.) Warm environments which speeds decomp.

*How should you position an obese body?*

1.) Head raised high of the table. ---> prevents purge. 2.) Position elbows close to the body. 3.) Keep head straight. 4.) tise feet together if needed.

Purge pre-embalming treatments:

1.) If the abdomen is distended from gas/ edema (ascites) prior to emb: ---> insert a trocar into the ventral area of cavity to pierce the transverse colon (to relieve gas) and the stomach (to release liquids). 2.) To drain ascites: ---> Use trocar to puncture lower left inguinal area and drain to relieve pressure.

3 easy ways to detect the presence of gas in a body

1.) It distends weak unsupported tissues (ie> eyelids and the tissues surrounding the eye orbit, the temples, the neck, and the backs of the hands). 2.) In an emb. body: distension of veins. 3.) crepitation.

Technique to prevent purge for an OBESE case:

1.) Restricted cervical 2.) INJECT BODY FIRST. 3.) ASPIRATE CAVITIES. 4.) EMB. head last after setting features.

Common conditions causing antemortem subcutaneous emphysema:

1.) Rib fractures that puncture the pleura or a lung. 2.) Puncture wounds of the thorax. 3.) Thoracic surgical procedures. 4.) CPR compression causing a fractured rib or sternum to puncture a lung or pleura. 5.) Tracheotomy surgery

If arterial solution is present in purge during arterial injection and drainage is occurring, what should be done?

inject a sufficient volume to satisfy the preservative demands of the body.

Embalming RENAL failure cases general requirments:

1.) Strong arterial solution. ---> 2% (+) strength. ---> 30-35 index fluid. 2.) After surface discolorations clear and circulation is est., arterial solution in subsequent injections can be increased in strength (OPTIONAL). 3.) restricted cervical is advised. ---> stronger strength for the trunk + less so for the head. 4.) Aspirate immediately after injection.

4 types of facial injury in which the skin is broken:

1.) abrasion, 2.) laceration, 3.) incision, 4.) compound fracture

5 types of facial injury in which the skin is not broken

1.) contusion, 2.) hematoma (swollen tissues) 3.) depressed fracture, 4.) ecchymosis, 5.) simple fracture

4 things that can lead to purge

1.) gas, 2.) visceral expansion, 3.) arterial solution, 4.) ascites & hydrothorax

how can purge be caused by arterial injection.

1.) injection at a fast rate of flow (esp. on bodies dead for long periods) causing visceral expansion. 2.) arterial solution can leake thru ulcerated vessels (stomach, upper bowel, lung) and fill the stomach, lungs.. etc and dev. into purge. 3.) If esophageal varices break, sufficient blood and arterial solution can exit to create purge. 4.) if GI bleeds and sufficient fluid leak from tissues, anal purge can result during injection. 5.) leakage of arterial fluid from aneurysm in abdom/thoracic cavities creating pressure. 6.) injection pressure can cause leakage in surgical incision filling cavities with solution and creating pressure.

Steps to protect the skin from purge:

1.) massage cream prior to or during injection. 2.) Tightly packing the throat, nostrils, ears, or anus with cotton during or after emb.

5 types of gases found in the tissues:

1.) subcutaneous emphysema. 2.) air from the embalming machine. 3.) gas gangrene. 4.) tissue gas. 5.) decomposition gas.

SOURCE OF GAS: ---> Air injected by the emb. machine (air pressure machines and hand pumps are in limited use). CHARACTERISTICS: ---> First evidence in eyelids. ---> no odors; no skin-slip. ---> amount depends on injection time. TREATMENT: ---> If distension is present, channeling after arterial injection to release gases.

AIR FROM THE EMB. APARATUS

1.) Orifice: ---> anal orifice 2.) Description: ---> semisolid/liquid. 3.) Contents: ---> fecal matter. ---> blood. --> arterial solution 4.) Time: ---> pre, during, postemb. 5.) TREATMENT: ---> Pre-emb. anal purge should be forced out by applying pressure to the lower abdomen. ---> continue to allow purging during injection. ---> anal orifice can be tightly packed with phenol soaked cotton AFTER cavity emb.

ANAL PURGE

SOURCE OF GAS: ---> Bacterial breakdown of body tissues. ---> Autolytic breakdown of body tissues. CHARACTERISTICS: ---> Possible odor. ---> Skin-slip in time. ---> color changes. ---> purging (caused by the accumulation of gasses). TREATMENT: ---> Arterial injection of sufficient amount/ strong chemical. ---> Hypo treatment/ surface treatment. ---> channeling to release gasses. ---> cavity aspiration to remove gases.

DECOMPOSITION

Alcholism cases:

EMB. COMPLICATIONS: 1.) LIVER FAILURE: ---> liver failure depletes the blood of clotting factors (good drainage expected). ---> Skeletal edema or ascites/hydrothorax often accompany liver failure. ---> potential jaundice. 2.) Difficulty firming tissues. EMB. TREATMENTS: 1.) Restricted cervical. 2.) moderate injection speed (to prevent swelling and purging and rupture of weakened esophageal veins). 3.) Counter-stain for jaundice. 4.) moderate to strong preservative. 5.) ecchymosis on the back of the hand can be treated with cav. fluid or phenol cautery chemical AFTER injection. 6.) Tissue build after injection. 7.) if ascites present: ----> before emb., puncture and drain serous fluid. ----> point the trocar beneath the surface of the anterior abdominal wall to avoid puncturing large vessels.

1.) Orifice: ---> Mouth ---> nose 2.) Description: ---> Frothy. ---> blood remains red. ---> little odor. 3.) Contents: ---> respiratory tract liquids. ---> residual air from lungs. ---> blood, ---> arterial solution. 4.) Time: ---> pre, during, postembalming. 5.) Causes: 1. TB infections, lung cancer, pneumonia, and bacterial infections of lungs can cause fluid loss they weakened capillaries. 2. Congestion of the R. atrium of the heart: -----> During injection, blood pushes on the R. atrium and cannot be drained away--> pressure builds--->blood flows to R. ventricle-->into pulmonary arteries and squeezes lung tissues-->forcing purge. 3. Rupture of small veins can produce bloody purge. 5.) TREATMENT:

LUNG PURGE

Should pre-injects be used on cases of renal failure??????

NO ---> if the circulation is impaired, tissues can easily swell.

GENERAL EMB. STEPS FOR FACIAL TRAUMA CASES:

PRE-EMB: 1.) Disinfect. 2.) wash debris/glass shards off. 3.) ALIGN FRACTURES. ---> incisions may have to be made to prop/align simple and depressed factures. 4.) ALIGN LACERATED/ INCISED SKIN. ---> superglue/ single bridge suture with floss. 5.) REMOVE LOOSE SKIN that cannot be emb. (scabs). 6.) can apply surface compresses now to help preserve/ bleach/ dry tissues. ---> (massage cream on delicate areas before). ARTERIAL EMB.: 7.) Prepare strong fluid. 3.) INSTANT TISSUE FIXATION. ---> strong arterial fluid. ---> restricted cervical for unautopsied bodies. ---> pressure = 20 psi. ---> As soon as fluid starts to flow, shut the valve off + wait a moment + repeat.

SOURCE OF GAS: ---> Puncture of lung/pleural sac. ---> Seen after CPR. ---> puncture wounds to thorax. ---> RIb fractures. ---> tracheotomy. ---> DOES NOT INVOLVE MICROBES. CHARACTERISTICS: ---> No odor. ---> No skin slip; No blebs. ----> Gas can reach distal points, even toes. ---> Can create intense swelling. ---> Rises to highest body areas (face/neck tissues). TREATMENT: ---> Gas escapes thru incisions. ---> Est. of good arterial preservation. ---> Channeling of tissues to release gasses. ---> Cavity aspiration of gasses. ---> Restricted cervical injection (use a stronger solution to emb. the head in order to firm the tissues more which creates sufficient resistance to any gas that wants to relocate into the facial tissues causing distension). ---> The 2 incisions used for Restricted cervical act as an exit for gasses and also can be used as points from which to channel the neck so air can be pushed from the facial tissues.

SUBCUTANEOUS EMPHYSEMA

2 factors responsible for decomposition:

bacterial & autolytic enzymes

when can purge occur? ---> locations?

before, during, and after emb. 1. stomach 2. brain 3. lung 4. anal

Generally, purge from the mouth, nose, or anus after cavity embalming is what? ---> How do you treat it?

cavity fluid that was injected. ---> tightly repack the orifices with cotton and replace moist cotton in the mouth with dry cotton.