Embalming chapter 16

Fluid Strengths and Volume (child): aspiration & cavity treatment

-A thorough aspiration of the cavities is necessary, followed by injection of sufficient concentrated cavity fluid to reach all areas of the cavities. -Reaspiration and reinjection of the cavities may be necessary.

Pressure and Rate of Flow of Injection (young adult/adult)

-An ideal speed of delivery, called rate of flow, is defined as the injection of 1 gallon of solution in a period of 10-15 minutes. Healthy body tissues can accept fluid at this rate of speed without distension. -Sufficient pressure and rate of flow should be used to overcome the resistances within the vessels and to distribute the arterial solution without causing tissue distension. A pressure setting of 5-20 psi (measured in pounds per square inch or psi) is sufficient to overcome most body resistances. --Many prefer low pressures; others prefer high pressures; some inject with 140 psi as the standard pressure. ---Speed of delivery is just as variable.

Infant Cavity treatment

-An infant trocar is selected for aspirating and injecting the cavities. Infant trocars are shorter in length and inside diameter than a standard trocar. The customary point of entry or a lower point such as the right or the left inguinal abdominal area may be used. -Cavity embalming can immediately follow arterial injection or be delayed for several hours. Injection of undiluted cavity chemical follows. The volume of cavity chemical varies with respect to the size of the infant. -The entry site is closed by a purse-string or reverse suture, or by a trocar button.

Arteriosclerosis & aneurysm

-Arteriosclerosis can also cause an aneurysm in a blood vessel. An aneurysm is an excessive bulging in the wall of a blood vessel, causing the wall to weaken. --Leakage of embalming solution during arterial injection will occur at the site of a ruptured aneurysm.

Closure of the Cranial Incisions: suturing method

-Begin suturing on the right side of the cranium and end on the left side. Select thin suture material and a small postmortem needle. -The inversion (worm) suture is ideal to invert the scalp tissues for a clean line of closure that may easily be concealed by hair, mortuary wax, or cosmetics. -Super adhesive glue provides a leakproof closure. A tight baseball or intradermal suture may also be used for closure.

Malignancy-Solution< volume, supplemental

-Cancer deaths are often attributed to pneumonia and respiratory arrest. Embalming solutions should be of moderate strength, at or above 2% and well-coordinated by the addition of supplemental chemicals such as coinjection. -Metabolic disturbances and renal and respiratory failure, often accompany malignancy. The result is a buildup of metabolic wastes in the tissues. -Waste products increase the demand for preservative.

Malignancy

-Cancers or neoplasms that begin as localized tumors can easily invade healthy tissues, spread via the blood vascular system, and invade organs. This can disrupt vital functioning to the point of death. -Both local and systemic effects of malignancy have an effect on embalming. Weight loss and emaciation produces unsupported, senile skin; loose and flabby. The skin can also be dry due to the inability of the body to retain proper water balance.

Cardiac Disease

-Cardiac disease may be treated by surgery such as heart bypass or valve repair. Incisions will be present when death occurs within days or a few weeks postsurgical. -Edema in the facial tissues is common when postsurgical therapies involve large volumes of intravenous fluids.

Fluid Strengths and Volume (child)

-Children require a smaller volume of fluid than adults, but a greater volume than that used for infants. -When contagious or infectious disease is the cause of death, the arterial solution strength should be of sufficient strength to sanitize the body tissues without any adverse effect to the appearance of the body.

Closure of the Cranial Incisions

-Coat the interior of the cranial vault with preservative autopsy gel and apply absorbent and preservative powders. -Add a quantity of cotton to fill the cranial cavity to absorb residual fluids and stabilize the calvarium once it is replaced. -Often, infants are held during the memorial event. To recreate weight in the head, form a ball with a small amount of modeling clay, wrap tightly in cotton, and place into the cranial cavity.

Various types of postmortem exams are performed on infants. What are the types?

-Complete autopsy: both cranial & trunk cavities are opened & internal organs removed for exam -partial autopsy: specific cavities are opened for exam -Local autopsy: specific organs are targeted for exam. the spine may be examed by dorsal approach

When embalming an infant, what should the infant be placed on to assist in positioning?

-Cotton or toweling can be placed beneath the head and shoulders to substitute for a head block. -Attention is also given to the positioning of the legs. Infant-sized caskets are customarily full couch design and the legs are visible.

Arthritic Conditions; positioning challanges

-Degenerative changes create numerous positioning challenges for the embalmer. It may be necessary to secure the body in position during embalming. -Positioning devices such as body bridges and head blocks placed beneath the thighs and shoulders provide adequate support. -Rolled bath towels placed under the shoulders also help to achieve temporary position. -Unintentionally, it is possible to tear tendons and atrophied muscles while positioning cases with severe conditions. Leaving the arms and legs in the original positions may be acceptable to the family. --It is not recommended that tendons or skin be cut to achieve good positioning. It is not possible to unclench severely arthritic fingers with causing harm.

Arthritic Conditions

-Degenerative physical changes occur naturally with age, such as arthritis, muscle atrophy, and osteoporosis. These conditions may be exacerbated in patients confined to a bed or otherwise incapacitated. -Muscle atrophy causes reduced skeletal muscle mass. The muscles of the extremities remain contracted and resist being straightened.

diabetes mellitus

-Diabetes mellitus is a group of diseases resulting in excess sugar in the blood. Insulin helps to regulate blood sugar level. Insulin therapy is a primary treatment for diabetes. -The principal manifestations of diabetes include hyperglycemia (excess sugar in the blood), glycosuria (sugar in the urine), and ketosis (acidosis characterized by the presence of ketones in the blood and the body tissues). -A strong odor of acetone may be noted due to its presence in the urine and the perspiration. -Pathologic changes include poor peripheral circulation, particularly in the lower extremities, and degenerative changes in small blood vessels.

What type of arterial fluid is used in the preservation of 4-12 year olds?

-Fluid strength is determined by the condition of the body. -Tissues are more delicate than adults. A medium-index fluid in the index range 18-25 is most satisfactory. -In cases of trauma and the effects of diseases, such as edema and renal failure, appropriate fluid strengths should be used and, if necessary, special-purpose high-index fluids.

Mouth closure for the advanced age

-Frequently a loss of weight is manifested in the facial tissues of the elderly. After mouth closure, place cotton or mortuary putty over the teeth or dentures to fill sunken areas of the cheeks. -Consider natural and acquired facial markings to avoid overfilling tissues. Atrophy of the two maxillary bones, the maxilla and mandible may prevent use of the needle injector method of mouth closure. A method of suturing is advised for mouth closure.

Hypodermic embalming the unautopsied infant

-Hypodermically treat the back, shoulders, trunk walls, buttocks, and external genitalia to ensure thorough preservation in these areas. An infant trocar or large-diameter hypodermic needle is ideal. -The head may be injected hypodermically from within the incision made for carotid artery injection, from the natural openings of the mouth and nostrils, or from beneath the autopsied scalp. -Arms and legs may be injected from within the open trunk cavities or from external points.

Surface Embalming Infant

-Internal compresses, referred to as inlays, are first saturated with chemical. Inlays can be placed into the interior of the neck, the cranium, and the trunk cavities. -Inlays can also be inserted under the pectoral chest flaps (over the sternum) before suturing the trunk. Preservative gels can be brushed onto surfaces such as the calvarium of the skull and the anterior chest and abdominal skin flaps prior to suturing. uCover compresses with plastic sheeting to prevent evaporation and release of fumes. External compresses of cotton saturated with undiluted cavity fluid or a topical preservative may be used to preserve areas as small as the ears or, in other cases, the entire body.

Vessel selection in non-autopsied infants: Common carotid artery

-Placing a support under the shoulders and lowering the head will bring vessels closer to the surface for ease in raising them. -Place a horizontal incision in one of the wrinkles in the neck. This type of incision is easily concealed after closure. -uSeal the incision with adhesive, subcutaneous suture, or the inversion (worm) suture. When drainage is insufficient, raise the left internal jugular vein.

As a general rule, should preinjection be used on infants?

-Pre-injection is not recommended as an embalming solution for embalming infants; the preservative content is low or none at all. Despite assumptions, infants may require higher solution strengths. -Modify the harshness of strong formulations with supplemental fluids, such as coinjections. Volume in solution injected will vary according to body size.

Diabetes Mellitus: EMB ALMING METHOD

-Restricted cervical injection is recommended. Two different arterial solutions can be used for separate injection of the trunk and head. -Cavity embalming should immediately follow arterial injection and be thorough. Fungal infections can be localized in the respiratory tract. -Inject liberal amounts of cavity fluid into the liver and the lungs. Place plastic garments on the lower extremities when ulcerations are present. -A recommended treatment is listed in your textbook.

Senile Purpura

-Senile purpura (or ecchymosis) is an extravascular irregularly shaped blood discoloration that often appears on the arms and the backs of the hands. -The condition is brought about by fragility of the capillaries. In the elderly, excessive medications, blood thinning drugs, vitamin deficiencies, uremia, hypertension, thin skin, and slight bruising can easily lead to senile purpura. -These discolorations vary greatly in size and do not clear during arterial injection.

Closure of the Cranial Incisions: Calvarium

-Several methods are used to secure the calvarium, such as calvarium clamps, drill and wire, and suturing. The inner surface of the reflected scalp and surface of the calvarium is likewise coated with preservative gel or mastic compound.

Cardiac Disease: vessels & solution

-The common carotid artery and the internal jugular vein is the ideal primary injection and drainage technique. -A moderate to strong arterial solution with the addition of dye helps to indicate the distribution of arterial fluid. When local obstructions exist, sectional embalming is necessary.

Pressure and Rate of Flow of Injection: first injection (young adult/adult)

-The first injection, while the vascular system is filling, should be slow to prevent arterial coagula from loosening and moving within the vessels. This method can also loosen coagula in the arteries creating arterial emboli that can block smaller arterial branches. -Multipoint injection and hypodermic embalming may then be necessary to effectively embalm tissues receiving insufficient preservation.

Feature setting infants: Lips

-The lips can remain slightly parted. When this is done, massage cream should be placed on the tongue and buccal cavities inside the mouth to prevent dehydration. -Only the corners of the mouth are glued. Create a relaxed mouth closure to produce a comfortable expression.

Pressure and Rate of Flow (child)

-The rate of flow should be a greater concern than pressure to the embalmer, especially when embalming a child. If arterial solution is injected too quickly into the body, the tissues may distend. •By the use of intermittent drainage, short-circuiting of solution is reduced and retention of solution is increased. •Rapid injection with continuous drainage often has the tendency to remove moisture from a child's tissues. This could lead to wrinkling of the skin.

Infant embalming solution (unautopsied)

-There are many suggested chemical combinations, strengths, and dilutions for infant arterial embalming. -One false theory is that infants must always be embalmed with very mild solutions and low-index arterial fluids. -Harsh tissue reactions can be reduced by the addition of supplemental fluids such as humectants and other types of coinjection chemicals. -Arterial fluids designed for infant use are available. The addition of trace amounts of dye to enhance complexion color is recommended.

Vessel selection in non-autopsied infants: Ascending aorta

-Use of the aorta for embalming an unautopsied infant requires the embalmer to make an external incision that resembles an autopsy. -The ascending aorta is also used as an injection point. -Drainage can be taken from the right auricle of the heart (the small ear-like appendage of the right atrium of the heart). Clip open the auricle to allow drainage. -The incision can be made down the midline of the sternum. Because the sternum is not yet ossified and remains a cartilage, a scalpel or surgical scissors can be used to make the incision. -u-The incision must be held open with some form of retraction to allow injection of the aorta. Another type of incision, the U-incision can be used. This is basically a flap incision. -The tissue is bluntly dissected to expose the sternum. The sternal cartilage is incised at its junction with the ribs and freed of its lateral attachments. The embalmer must open the pericardium and expose the heart and its great vessels. -The entire body can be embalmed using this one-point injection method.

Vessel selection in non-autopsied infants: Abdominal aorta

-Use of the aorta for embalming an unautopsied infant requires the embalmer to make an external incision that resembles an autopsy. The abdominal aorta is very large artery for use as an injection point. -Both artery and vein are deep-seated, resting on the anterior surface of the spine. -A small incision can be made just to the left of the midline in the middle of the abdomen, and inferior to avoid the liver. The liver is usually large in the infant. The omentum is a large flat adipose tissue layer nestling on the surface of the intraperitoneal organs. -The omentum must be opened and a portion of the small and large intestines resected from the spine to visualize the vessels. -The vein can be opened and the blood passively drained into the cavities. Use of a drainage instrument placed into the vein is unnecessary. The lower portion of the body should be injected first, then the upper portion. -During injection, the intestines can greatly expand. Release any fluids by clipping the intestines with surgical scissors. The entire body can be embalmed using this one-point injection method.

Cardiac Disease: incisions

-When recent incision closures leak during injection, suture overtop the existing staples or sutures, or remove them altogether and apply a new closure. -Remove metal staples with a hemostat. •Dry the incisions and hypodermically treat discolored or inflamed tissue margins; this can be a sign of infection.

Arthritic Conditions: vessel selection

-When the legs are drawn to one side or into the fetal position, use of the femoral vessels is limited. -The common carotid would be the best site for injection. If it becomes necessary to inject the legs, an attempt can be made to raise the femoral or external iliac artery. The popliteal artery may also be a choice. -If these vessels are found to be sclerotic, an attempt should be made to inject using a small arterial tube.

Infant considerations; In addition to moisture:

-congenital disease processes and medications can further increase moisture and waste products in the tissues. Renal and liver failure can cause accumulation of waste products. -Both greatly increase the preservative demand of the body.

What are the 2 major injection sites used in embalming the adult also used for embalming the child?

1. The common carotid artery and the internal jugular vein 2. The femoral artery and femoral vein. -There is no need to consider use of the abdominal aorta or the arch of the aorta in this age group. -The many disadvantages of the axillary artery and vein do not make this a good primary injection site.

Many in this age group (child) are autopsied, so most of the embalming is done from the primary autopsy sites

1. right and left common carotid, 2. right and left external and 3. internal iliac 4. right and left subclavian arteries. -Some embalmers prefer the femoral vessels for this age group strictly because their location permits the use of clothing that can be opened at the neck. -The possibility of leakage or visibility of the carotid incision should be of little concern if properly prepared, sutured, and sealed.

At one year of age, body fat increases to

30%

At 1 year of age, water weight declines to around

60%, similar to an adult.

At birth, the body water present is approximately

75% of total body weight.

Vessel selection in non-autopsied infants

All arteries should be usable; size is the varying factor. The common carotid is the largest, easily accessible, and very shallow. The common carotid artery is accompanied by a large vein, the internal jugular vein.

Infant considerations: arteries & veins

Arteries and veins are small; a variety of arterial tubes in different diameters and lengths are necessary. Small bore sizes will easily clog. -Best practice is to insert a needle injector wire through the barrel to clear any debris. The wire can remain for instrument storage.

The particular age of a decedent can cause the embalmer to expect conditions common to a particular age category.

Embalming considerations such as vessel selection, injection and drainage techniques, strength and volume of embalming solution, and injection pressure and rate of flow are all influenced by the age of the decedent.

Feature setting infants: eyecaps

Eye caps may be trimmed with scissors to fit beneath small eyelids. Cotton may be used in place of eye caps. Apply a thin film of massage cream or spray to maintain eye closure and prevent tissue dehydration.

Fetuses and Preterm Infants

Fetuses should be preserved by supplemental hypodermic and surface methods; arterial injection is likely impractical. Supplemental treatments are effective to stabilize the fetus until final disposition. -Viewing the fetus or preterm infant is an individual choice. Size of the preterm infant determines the embalming method. All three methods are suitable.

Arteriosclerosis & gangrene

Gangrene may also be present. Treat wet gangrene hypodermically with a cauterizing chemical, apply a compress covered with plastic sheeting. Gangrene of a limb can be dressed in a plastic garment.

Infant considerations: skin

Infant skin is delicate and can easily distend, are too harsh, injected too rapidly, and under high pressure.

What part of the body should be injected first for the unautopsied infant?

Inject the legs and arms prior to injecting the head so that solution adjustments can be made.

Supplemental Fluids (young adult/adult)

Supplemental chemicals can be used in the embalming of all bodies. These chemicals are designed to enhance the preservative and disinfecting qualities of the preservative fluids, control moisture, add color to the tissues, and adjust pH of the tissues as well as the arterial solution.

Closure of the Trunk Incisions: abdominal, thoracic, and pelvic cavities

The abdominal, thoracic, and pelvic cavities should be coated with autopsy gel or a preservative absorbent compound following aspiration and drying of the cavities. Fill the cavities with absorbent material, such as cotton; saturate the material with a preservative chemical.

Infant cavity aspiration uses which two points of injection?

The customary point of entry or a lower point such as the right or the left inguinal abdominal area may be used

Feature setting infants: Mouth closure

The needle injector method of closure is impractical due to the unossified jaw bones. The barb will not properly embed in the soft bone. A musculature or other suture method can be used effectively. An adhesive glue applied to the lips can substitute for suturing.

Closure of the Cranial incisions: scalp

The scalp is drawn back to its normal position and sutured. The fontanelles are the spaces between the bones of the skull in the fetus and young infant. Bone ossification is not complete and the sutures of the cranium are not fully formed.

Vessel selection in non-autopsied infants: Femoral or external iliac artery

The second largest nonaortic vessels are the external iliac and femoral arteries. The external iliac is slightly larger than the femoral. The accompanying veins are relatively large and may be used for drainage. -If a small drain tube is not available, these veins can be expanded by inserting a small forceps into the vessels.

Closure of the Trunk Incisions:

The sternum (breast plate) is properly oriented before replacing it to cover the open cavity. Webbed cotton can be applied to overtop the sternum and saturated with preservative chemical. -The skin flaps are held together with gathering forceps to ensure proper alignment; suturing begins at the pubic symphysis and is directed superiorly. --A tight baseball suture provides a good closure.

Vessel selection: Children

The vessels of children are larger than those of the infant, but still smaller than those of the adult. Arteries should be in ideal condition and free of arteriosclerosis.

Vessel selection in non-autopsied infants: Axillary artery

Use of the axillary artery may be impractical for efficient embalming of the entire body. The vessel is very small.

Closure of the Cranial Incisions: Fontanelles

When the fontanelles are still present, fill the cranial cavity with cotton to create natural contour. The soft bone plates are aligned and sutured together with fine thread or dental floss and a small postmortem needle. Apply mortuary putty to cover the fontanelles. This mastic material will hold the soft cranial plates in place and prevent leakage. The mastic will also adhere to the interior surface of the scalp and prevent slippage during suturing.

Body fat in the newborn is approximately

total body weight and doubles to 25% at 6 months of age.

Arteriosclerosis: classic signs of abdominal aortic aneurysm rupture

uClassic signs that an abdominal aortic aneurysm has ruptured: upon injection there is little to no blood drainage, the abdomen distends abruptly, and solution distribution is not observed. uA six-point injection is necessary. Following sectional injection, hypodermically treat the trunk walls to ensure preservation.

Advanced age

•Life expectancy in the United States in 2020: 75.1 years for men and 80.5 years for women. Embalmers customarily embalm greater numbers in the advanced age group. •The number of persons living into their late eighties and nineties is expected to double within several years. It is useful to identify common conditions associated with advanced age.

Senile Purpura signs & treatment

•Often, the affected area becomes engorged with fluid and swells during arterial injection. •Handle areas of the hands affected by purpura with caution; tissues easily tear. -When senile purpura is present over the hands and the arms, and often the base of the neck, the arterial solution should be strengthened.

General infant positioning guidelines

•Positioning varies considerably. The arms can be positioned at the sides of the body or the forearms and hands placed upon the abdomen. •A toy or stuffed animal is often placed in the hands. The head may be turned slightly to rest on the right cheek for a relaxed or sleeping pose.

Setting of Features and Positioning (child)

•The arms can be more relaxed than those of the adult and the head positioned with a similar slight tilt to the right. •Mouth closure may also be more relaxed than an adult. Lips may be fuller than the adult. -Some drugs stimulate the growth of facial hair; this fine hair can easily be shaved to prevent a negative impact on cosmetic application. -Cosmetics can stick to fine facial hair and produce an unnatural appearance.

Arteriosclerosis

•The artery most frequently affected by sclerosis is the femoral artery. •The common carotid artery is the best primary choice when sclerosis is present in the femoral vessels. Rarely is the carotid found to be sclerotic.

Infant (unautopsied) embalming solution Volume & strength

•Volume is determined per case. Best practice is to raise and ligate all arteries prior to injection of embalming solution. •The additional time necessary to raise arteries during arterial injection unnecessarily exposes the embalmer to chemical fumes.