Embalming II Chapter 21 SPCollege Review

Darken Skin

- Corrected by cosmetic application - use fluid dyes to ensure fluid distribution to all body areas

Pitting Edema "Problems"

- Distension - fluid dilution - leakage - difficult preservation

Anasarca Edema "Problems"

- Leakage - distension - arterial fluid dilution

Pitting Edema "Treatment"

- May be gravitated - use strong arterial solutions - may be punctured and drained - use plastic garments to protect from leakage

desiccated lips, eyelids, or fingertips

- May need correction with restorative waxes - tissue building - opaque cosmetics needed to hide discolorations

Solid Edema "Treatment"

- Must be excised for reduction - strong arterial solutions - coinjection fluids

Ascites Edema "Problems"

- Pressure can cause purge of stomach contents - anal purge - dilution of cavity fluid

Hydrothorax Edema "Problems"

- Purge - dilution of cavity fluid - pressure can cause venous congestion of neck and face - facial distension

Edema of Face "Treatment"

- Restricted cervical injection - strong coordinated arterial solutions - possible use of salt solutions or high index solutions to reduce swelling - elevate head - channel with trocar neck area for drainage into thorax - surface weights for eyes and lips - surface and hypodermic embalming to ensure preservation with cavity

Firm feel to the skin

- Skin feels embalmed - additional dye helps to trace the distribution of fluid

Solid Edema "Problems"

- Swollen tissues - difficult preservation

Dehydration created by the embalmer; wrinkled lips, fingertips; facial areas

- Use correct dilutions for arterial and humectant fluids - areas may be filled out with tissue builder after embalming

Dehydration of large facial area from embalming and passage of air over body

- Use massage cream on exposed ares prior to cosmetic application - if skin is discolored, opaque cosmetics will be needed - cream cosmetics further reduce dehydration - fingertips and facial areas may also be treated with tissue builder to reduce dehydration

Flaking or peeling of skin, especially in facial areas

- apply massage cream and then clean with a solvent to remove all loose skin - mortuary cream cosmetics further reduce skin drying

Hydrothorax Edema "Treatment"

- aspiration - injection of cavity fluid - careful draining prior to arterial injection

Ascites Edema "Treatment"

- aspiration and injection of undiluted cavity fluid - preembalming draining via trocar or drainage tube - reaspiration and reinjection

Hydrocele Edema "Treatment"

- channel with trocar to drain into abdominal cavity - inject via trocar undiluted cavity fluid - surface coating with autopsy gel - use of plastic garments and embalming powder

Edema of Legs "Problems"

- dilution of arterial solution - leakage

Hydrocephalus Edema "Treatment"

- drain in infant via ethmoid foramen - inject cavity fluid via ethmoid foramen

Hydrocele Edema "Problem"

- leakage - dilution of arterial solution - distension - problems in dressing

Thickened Blood

- may be diluted with a preinjection fluid - use right internal jugular as drainage point - inject from the carotids to push arterial coagula toward the lower extremities

Edema of hands "Treatment"

- sectional injection from axillary artery - surface packs with cavity fluid to ensure preservation - bleach any discolorations - elevate to gravitate edema into arm

Edema of Legs "Treatment"

- sectional injection of legs from femoral or external iliac artery - use of strong arterial solutions - use of salt solutions or dehydrating solutions to remove edema - hypodermic injection with undiluted cavity fluid - surface treatment using autopsy gel - plastic stockings containing embalming powder and autopsy gel - elevate to gravitate edema into abdominal cavity - puncture and drain

Anasarca Edema "Treatment"

- strong arterial solutions - hypodermic and surface embalming - plastic garments - gravitation - puncture and drain

Edema of hands "Problems"

- swollen tissues - possible leakage from intravenous punctures - wrinkles after removal

EMBALMING PROBLEMS CREATED BY ANASARCA

1. Affected tissues are swollen with fluid. 2. When edema gravitates or moves from a region, the skin can wrinkle and appear distorted. 3. Fluid can leak from intravenous or invasive punctures through the skin surface by gravitation, through hypodermic needle punctures, through surgical incisions, and through incisions made for embalming purposes. 4. Arterial fluid is diluted (secondary dilution). 5. Decomposition is speeded. 6. The possibility of separation of the skin layers (skin-slip) is increased. When the face is affected by edema, the embalmer must first determine whether solid or pitting edema is involved. This can be done by gently applying digital pressure to the swollen tissues. Solid edema cannot be indented by pressure from the fingers. With solid edema, the extra fluids are located within the individual cells of the tissues. This type of edema is seen in allergic reactions and as the result of certain drug therapies, such as the extended use of corticosteroid drugs. Solid edema cannot be removed by arterial or mechanical means. It would not be wise to attempt to reduce the swelling by surgical removal of subcutaneous tissues after arterial embalming. Uniformity of the tissue reduction and leakage would be major concerns. Solid edema, especially of the facial tissues, is not as frequently encountered as pitting edema. In pitting edema, the fluid is in the interstitial spaces (between the cells). Pitting edema can be gravitated. Merely elevating the head helps to drain some of the fluid from the tissue spaces. Elevation of the head and the shoulders, during and following arterial injection, can drain a considerable amount of edematous fluids from the facial tissues. Passing the trocar through the tissues of the neck, while aspirating, will provide channels through which these fluids can pass from the the face into the thorax. A sufficient amount must be given for this drainage to occur.

Chronic Renal Failure - Summarized

1. Decomposition occurs rapidly. 2. Acidosis alters the reaction between proteins and the preservative. 3. The body appears sallow because urochrome is present in the tissues. 4. Sites of gastrointestinal bleeding may be sites of arterial fluid loss and sources of purge. 5. Edema dilutes the arterial fluid. 6. Uremic wastes in the blood and tissues neutralize preservatives. 7. Skin infections may be caused by uremic pruritis.

Antemortem Dehydration

A number of disease processes can result in a loss of fluid from the body cells and tissues: hemorrhage, febrile diseases, kidney diseases, diabetes, some cancers and localized neoplasms, and some first-degree burns. For many years, tuberculosis was a classic example of a disease whose symptoms produced severe emaciation and dehydration. More recently, emaciation and dehydration were seen in the early years of AIDS. However, most patients today under medical care are given hydrating therapies, so the "classic" dehydrated body is rarely seen. Those bodies that do exhibit severe dehydration are of persons who either did not seek medical treatment or withdrawn treatment under physician care as in some hospice situations.

Edema of the Body Cavities

Ascites is edema of the abdominal (or peritoneal) cavity; the edema is found within the cavity and surrounds the abdominal viscera. Hydrothorax is edema of the pleural cavity; it may involve one or both pleural cavities. Hydro-cephalus is edema of the cranial cavity, and hydropericardium is edema of the pericardial sac surrounding the heart. Hydrocele is an accumulation of serous fluid in the saclike cavity in the tunica vaginalis testis of the male scrotum. Edema of the cavities does not dilute the arterial solution. If the body being prepared has ascites, it is not necessary to increase the strength of the arterial solution because of the edema in the abdominal cavity. Edema of the cavities does not mix with the arterial solution. The embalmer's concern is that the edema in the abdominal cavity might dilute the cavity fluid when it is injected.

Pulmonary Edema "Treatment"

Aspiration and injection of lungs

Hypopericardium Edema "Treatment"

Aspiration and injection of undiluted cavity fluid

Reducing chemicals:

Chemicals used to constrict or dry tissues, usually containing phenol or a phenol derivative. May be combined with other reducing techniques such as external pressure, channeling, incising, and aspiration. Type of swelling reduced: liquids and semisolids.

Postmortem Dehydration— Preembalming

Dehydration following death is classified as a postmortem physical change. Following death and before embalming of the body, refrigeration and gravitation can remove moisture from the upper areas of the body such as the face and the neck. If the body is refrigerated, the dry, cool air moves around the body and gradually draws the moisture in the tissues to the surface of the body and into the surrounding air. (Refrigerated bodies are discussed in Chapter 19.) Even the unrefrigerated bodies exposed to environmental forced air heating and air conditioning can rapidly dehydrate. Refrigeration also helps to keep the blood in a fluid state. Thus, the blood and the tissue fluids slowly gravitate (hypostasis) to the dependent tissues of the body. The upper areas of the body lose moisture because of the surface evaporation and the gravitation of fluids. Gradually the viscosity of the blood will thicken due to loss of moisture. This will increase postmortem coagula in the vascular system. Postmortem emboli in the arteries prevent a good distribution of the arterial embalming solution and coagula in the veins can make drainage difficult to establish.

Hypopericardium Edema "Problem"

Dilution of cavity fluid pressure could cause drainage problems

Edema of Face "Definition"

Edema in facial tissue

Pulmonary Edema "Definition"

Edema in the alveoli of the lungs

Hydrothorax Edema "Definition"

Edema in the thoracic cavity

Edema of Legs "Definition"

Edema in thighs and lower legs

Pitting Edema "Definition"

Edema in tissue spaces, between the cells

Edema of hands "Definition"

Edema in tissues of the backs of the hands

Ascites Edema "Definition"

Edema of abdominal cavity

Hydrocephalus Edema "Definition"

Edema of cranial cavity

Hypopericardium Edema "Definition"

Edema of pericardial cavity

Hydrocele Edema "Definition"

Edema of scrotum

Solid Edema "Definition"

Edema within body cells

Anasarca Edema "Definition"

Generalized edema in all body tissues

ARTERIAL TREATMENT FOR GENERALIZED EDEMA

Generalized edema presents a number of problems for the embalmer. First and foremost is the increased rate of decomposition resulting from the presence of a large amount of body moisture. Water is necessary for decomposition. In generalized edema, vast quantities of water can be found in almost all the dependent skeletal tissues. In addition, the excess moisture causes a great secondary dilution of the arterial fluid, reducing the ability of the embalming solution to dry, sanitize, and preserve. The edema will, in time, seep through the skin, soiling the clothing and the casket interior. The large blebs that can form at edematous sites can break open and release fluids. The objectives of the embalmer are to: (1) inject an arterial solution of sufficient strength and volume to counteract the secondary dilution that occurs in the tissues and (2) remove as much of the edema from the tissues as possible. It is very important that the embalmer should know what condition caused the edema. For example, generalized edema can be the result of heart disease or renal failure. With renal failure, in addition to the edema, there is a buildup of nitrogenous wastes in the tissues. The nitrogenous wastes have the ability to neutralize the preservative solution. Therefore, very astringent solutions should be used. Edema also coexists with nitrogenous wastes in the bodies dead from second-degree burns, especially when the patient lived several days or weeks after being burned. These bodies demand large amounts of preservation solution. Edema can be present in all body types. Edema can and does quite often exist in emaciated bodies. The first concern, even in an emaciated body, is to achieve preservation and dry the tissues. Overdehydration of the face and the features is best avoided by raising both common carotid arteries at the beginning of the embalming and injecting the head separately. Frequently in cases such as cancer of the liver, the body with generalized edema may also be jaundiced. Again, of primary importance are the preservation and the drying of the tissues. The discoloration is secondary. Only the face and the hands will be viewed. The restricted cervical method of injection allows the head to be embalmed separately. A jaundice fluid could be employed for embalming the head and a strong arterial solution in large amounts for the preparation of the trunk. When arterial methods have not been completely successful, hypodermic injection of cavity fluid (or concentrated arterial solution) via the embalming machine can be used to inject local body areas. A small trocar can be used for the injection. The puncture is easily closed with a trocar button. Application of super adhesive around the trocar button helps to prevent leakage. The body is clothed in plastic garments. This technique works well with edematous legs.

Pulmonary Edema "Problems"

Purge

Hydrocephalus Edema "Problem"

Purge in infant

Acidosis brought on

by toxic waste in blood and tissues of the body.

Cellular (Solid) Edema

When moisture is retained by the cell, or abnormal amounts of moisture are allowed to pass into the cell, a condition called solid edema results. The tissues appear swollen and, when pushed on by the embalmer, feel very firm. Indentations are not made by pushing on these tissues. Frequently, this condition arises when large doses of corticosteroids have been administered over a long period. This form of edema, often seen in the facial tissues, does not respond to embalming treatments. The swelling and the distortion remain. The only possible, although not practical, method of reducing the swelling is excision of the deep tissues after arterial treatment is completed.

Ascites

When the abdomen is tightly distended, the embalmer should determine if the distension is caused by gas or edema. Often, simply the insertion of the trocar into the upper areas of the abdomen can determine the difference. If there is generalized edema of the tissues and tortuous veins are visible over the abdominal wall, the presence of edema in the abdomen (ascites) can be expected. If the abdomen is very tense some of this fluid should be removed prior to arterial injection, for it will create a resistance to the flow of arterial solution and interfere with blood drainage.

EMBALMING PROBLEMS CREATED BY EDEMA

Generalized edema presents a number of problems for the embalmer. The tissues in which edema is present are swollen. When this involves the face and the hands, measures must be taken to reduce the distortion. Edema of the skeletal tissues has a tendency to gravitate into the dependent body areas, during life as well as after death. In the bedridden patient, the edema is found largely in the dependent areas such as the back, the buttocks, the shoulders, and the backs of the legs. After death, this edema in the dependent tissues can in time lead to the passage of this fluid through the skin. This exit of fluid from the body can dampen the clothing of the deceased and the casket bedding, unless precautions are taken (e.g., use plastic garments and absorbent powders to trap and hold the fluids). Bodies with large amounts of edema also exhibit leakage from intravenous punctures and small openings such as those made with hypodermic needles. Any surgical or embalming incisions are possible sites of leakage. Another major concern with edema is that the excess moisture in the tissues will hasten the decomposition cycle. A good, moist environment for bacterial growth is provided. Autolytic and hydrolytic enzymes will have an ample source of water for their role in decomposition. A secondary dilution of the embalming fluid is created by this excess fluid.

Intercellular (Pitting) Edema

In intercellular edema, fluids accumulate between the cells of the body. When these swollen areas are pushed on by the embalmer, the imprint of the fingers remains for a short period after the fingers are withdrawn. This form of edema, also known as pitting edema (Fig. 21- 3), responds well to embalming treatments and can be gravitated to the dependent body areas. It can be drained from the tissues into the circulatory system and removed with the blood drainage. This edema may be localized as is frequently seen in bodies dead from cardiac diseases where only the legs are distended, and pulmonary edema (edema of the alveolar spaces in the lung tissue). Or, it may be generalized as is frequently encountered after death from liver or renal failure. Generalized edema is referred to as anasarca.

Edema Methods of Treatment

In treating the body with generalized edema, the embalmer should realize that large amounts of arterial solution must often be injected. Generally, the facial tissues are not affected by the edema (because in life the head is kept elevated), so to control the amount of the arterial fluid entering the facial tissues it is wise to use restricted cervical injection. In this method, both right and left common carotid arteries are raised at the start of the embalming. The left artery is opened and a large tube is inserted toward the head; the lower portion of the artery is ligated. A tube directed toward the head is placed in the right artery, as is a tube directed toward the trunk. Both tubes directed toward the head remain open during the injection of the trunk. In some of these treatments, several gallons of arterial solution are injected or waterless solutions are employed. The fluid that enters the head and the facial areas exits through the open tubes while the lower portion of the body is being injected (Fig. 21- 4). After satisfactory injection of the lower portion, the head can then be injected using a strength and quantity of arterial solution desired by the embalmer.

Desiccation

Regardless of the antemortem or postmortem conditions that have brought about the condition of dehydration, there is only one positive benefit to the embalmer. Dehydrated bodies tend to decompose more slowly, as water is necessary for decomposition. Extreme dehydration is called desiccation. Desiccation is a form of preservation; however, desiccated bodies are not viewable. Often, certain areas are desiccated in bodies that have been frozen or refrigerated for a long period. For example, desiccated lips appear black, very wrinkled, and shrunken. The lips are drawn back and the teeth are exposed. When the tips of the fingers are desiccated, the skin becomes parchment like and turns a yellow brown. Other body areas easily desiccated are the thin skin areas such as the ears, the nose, and the eyelids. Arterial injection or hypodermic injection is very ineffective in correcting this problem.

Edema of Face "Problems"

Swollen tissues, eyelids and tongue