Ch. 24: Selected Conditions

What is the treatment of Subcutaneous Emphysema?

-Allow gas to escape through incisions -Establish good arterial preservation -Channeling of tissues after arterial injection to release gases -Best to remove gas from tissues AFTER body is embalmed.

What is the source of Gas Gangrene

-Anaerobic -Clostridum Perfringens

What is the source of True Tissue Gas?

-Anaerobic bacteria (gas gangrene) -Clostridium Perfringens

How can the skin be protected from purge?

By applying a light coating elf massage cream to the facial tissues and neck area.

Most common cause of Candidiasis Causes THRUSH, which affects the oral mucosa and pharynx. Seen most often in infants/children. Lesions: white patches on mucosa.

Candida albicans

What are the contents of cavity fluid purge?

Cavity fluid

What time frame does embalming solution purge occur?

Embalming

What are the contents of anal purge?

Fecal matter Blood Arterial solution

How is purge generally described?

Generally described by its source- stomach, lung, brain, and anal

What do phycomycetes invade and cause?

Invade vessels and cause Thrombosis and Infarction.

What does gas gangrene do?

It ferments the sugars in tissue releasing great amounts of gas. The toxins break down the red blood cells.

What time frame does anal purge occur?

Preembalming Embalming Postembalming

What time frame does brain purge occur?

Preembalming Embalming Postembalming

What time frame does esophageal varices purge occur?

Preembalming Embalming Postembalming

What time frame does lung purge occur?

Preembalming Embalming Postembalming

What are the contents of lung purge?

Respiratory tract liquids Residual air from lungs Blood Arterial solution

Signs of Renal Failure

SALLOW color to skin as a result of UROCHROME buildup. Uremic pruritus (scratch marks on extremities) Increase in amount of Urea, Uric acid, Ammonia, & Creatine (Urea and Ammonia can be detected by their odor). Acidosis Edema Anemia Gastrointestinal bleeding

What is the portal of entry for Histoplasm capsulatum?

The lungs

What are the embalming suggestions for renal failure?

Use a strong arterial solution. Don't pre-inject. Use restricted cervical injection. Aspirate immediately after embalming

How does Visceral expansion cause purge?

When bodies have been dead for several hours and arterial solution is injected too fast the hollow visceral organs tend to expand. 1. Because the abdomen is a closed cavity this expansion creates sufficient pressure to push on the stomach walls and create a stomach purge. 2. This also pushes on the diaphragm and squeezes on the lungs possibly resulting in lung purge.

How can ascites and hydrothorax act as a source of purge?

When edema fills the thoracic or abdominal cavity prior to death, a great amount of pressure builds up and, or injection of arterial solution forces purge.

Describe Brain purge.

White semisolid

How many hours does swelling with gas occur?

Within hours

What is a fatal disease caused by infection of a wound?

gas gangrene

What are the characteristics of air from the embalming apparatus in the body?

First evidence in eyelids No skin slip Amount depends on injection time

What can be done to treat preembalming anal purge?

Force all of the anal purge from the body by applying firm pressure to the lower abdomen and flushed away with running water.

What orifice will brain purge exit?

Fracture in skull; Nose; Fractured ethmoid; Fractured ear; Temporal bone; Surgical opening

Caused by the oval, yeast like organism Histoplasm capsulatum. Occurs worldwide, but primarily common in Mississippi Valley of the US. May spread throughout body. Contracted from soil contaminated with fecal matter of chickens, pigeons, starlings, other birds, bats. Endemic in many parts of the world, particularly near large rivers, high humidity warm temperature regions.

Histoplasmosis (Reticuloendothelial Cytomycosis)

What is the treatment of air from the embalming apparatus in the body?

If distention is present, channeling after arterial injection to release gases

Describe the restricted cervical injection method.

In the unautopsied body, restricted cervical injection can be used (right and left common carotid arteries are raised at the beginning of the embalming). Insert two arterial tubes into the right common carotid, one directed towards the trunk of the head. Open the left common carotid artery, tie off the lower portion of the artery, and insert one tube into the artery directed toward the left side of the head. Leave both arterial tubes directed toward the head open. Inject the truck the trunk first, then in the left side of the head, and, finally, the right side. Drainage can be taken from the right internal jugular vein.

Describe Stomach purge.

Liquid/semisolid "Coffee grounds" appearance Foul odor Acids in pH

Alcoholism

Many bodies exhibit Jaundice as a result of liver failure. Liver failure can cause skeletal edema in the tissues or cavities. Hepatic failure depletes the blood of clotting factors; therefore good drainage can be expected. Inject at a moderate rate of flow. Purge is common (first bloody, then fluid) Firming difficult to establish.

Acute Disseminated Histoplasmosis

May be Benign or Progressive Acute Progressive Form is rapidly fatal & usually seen in young children or AIDS adults. Spleen, Lymph Nodes and Liver enlarged. There is a septic type with Anemia and Leukopenia.

Chronic Disseminated Histoplasmosis

May occur in elderly & otherwise healthy individuals. May be fatal. Clinical features vary according to organ most severely involved. Involvement of heart valves leads to Endocarditis. Involvement of Adrenal Glands leads to Addison's Disease. Other organs that can be affected: GI tract, spleen, liver, lymph nodes, lungs, bone marrow, meninges.

What orifice will cavity fluid purge exit?

Mouth Nose Anal orifice

What orifice will esophageal varices purge exit?

Mouth Nose

What orifice will lung purge exit?

Mouth Nose

What orifice will stomach purge exit?

Mouth Nose

What orifice will embalming solution purge exit?

Mouth Nose Anus Ear

Fungal infections that may have been present as an antemortem condition or occurred as the result of a Postmortem invasion. The fungi may be Saprophytic or Parasitic.

Mycotic Infections

What are the characteristics of subcutaneous emphysema?

No odor, no skin slip, no blebs. Gas can reach distal points, even toes Gas can create intense swelling and can rise to higher body parts such as neck and face. -NOT caused by a microbe & does not intensify after death.

An Infection of the Lungs, Ears, Nervous System, Intestinal Tract caused by a fungus commonly encountered as a Saprophyte or a contaminant. Lesions may display an intense necrotizing and suppurative inflammation process. Commonly called Mucormycosis, May be caused by several members of the group Phycomycetes

Phycomycosis

What are the characteristics of decomposition?

Possible odor, Desquamation over time, Color changes, Purge.

What time frame does cavity fluid purge occur?

Post embalming

What time frame does stomach purge occur?

Preembalming Embalming Postembalming

Why is it important to protect the skin from purge?

Stomach purge could occur which contains hydrochloric acid and can desiccate and discolor the skin. If arterial fluid is contained in the purge material, the dye from the fluid can stain the skin.

What is the treatment for Gas Gangrene?

Strong arterial solutions; Local hypodermic injection of cavity chemical

Describe the gas gangrenous process

The skin, dark red at first, turns green and then black, and there is considerable swelling that extends rapidly over the body. The tissues are filled with gas, sometimes to the point of bursting. The affected tissue decomposes, blisters, and skin-slip form on the surface, and there is no line of demarcation

What can be done to prevent purge?

Thoroughly aspirate the body cavities Inject additional cavity fluid when needed. Re-aspirate, often. Pack ALL orifices if leaking is a problem. Re-pack if necessary. Keep checking the body. Go into the state room often and make sure no additional treatments need to be done.

What is the first concern with embalming an obese body?

positioning

Instant Tissue Fixation ("Head Freeze")

-Use a strong arterial fluid. -Pressure gauge 20 psi or higher. -Inject left common carotid. (In the autopsied body, internal carotid may need to be clamped)

What are the contents of embalming solution purge?

Arterial solution

Where does gas gangrenous process begin?

At the margins of the wound

Describe Esophageal varices purge.

Bloody liquid

What are the contents of brain purge?

Brain tissue Blood Arterial solution

List injuries in which the skin is not broken Skin

Depressed Fractures Swollen Tissues (Hematoma) Ecchymosis Simple Fracture Contusion

Who is Phycomycosis especially seen in?

Especially seen in patients with uncontrolled Diabetes mellitus, leukemia, AIDS.

Describe Lung purge.

Frothy Blood remains red Little odor

In the preparation of bodies with Facial Trauma what is the embalmers Goal?

Maximize tissue preservation with a minimum amount of swelling.

Acute Pulmonary Histoplasmosis

May be asymptomatic or symptomatic. Basic reaction in lungs & lymph nodes consist of foci of tuberculoid granulomas that tend to heal.

List Phycomycetes

Mucor, Rhizopus and Absidia.

-Postmortem evacuation of any substance from any external body orifice as a result of pressure. -May occur prior to, during, and after embalming.

Purge

Describe Anal purge.

Semisolid/liquid

Conditions Predisposing to Tissue Gas

-Recent abdominal surgery -Presence of gangrene at time of death -Intestinal perforations or ulcerations -Contaminated skin wounds or punctures -Intestinal obstruction or hemorrhage -Unsatisfactory embalming -Contact with contaminated instruments

What is the Treatment for Tissue Gas?

-Special tissue gas arterial solutions -Localized hypodermic injection of cavity fluid -Channeling of tissue to facilitate gas removal

What is the Treatment for Decomposition

-Sufficient amounts of the appropriately strong arterial solution must be injected. -Hypodermic & Surface treatments may be indicated. -Channeling to release gases.

What are the Characteristics of True Tissue Gas?

-Very strong odor of decomposition -Desquamation; skin blebs -Increase in the intensity and amount of gas -Possible transfer of spore forming bacteria via instruments to other bodies

Describe Embalming solution purge.

Color of arterial solution injected

Describe Cavity fluid purge.

Color of cavity fluid Blood present is brown in color

What are the 2 Categories of Blunt Force Facial Trauma?

1. Injuries in which the skin is broken (abrasion, laceration) 2. Injuries in which the skin is not broken (contusion, hematoma)

What are the five types of gas that may be found in the tissues of the human body?

1. Subcutaneous emphysema 2. Air from the embalming apparatus 3. Gas gangrene 4. Tissue gas 5. Decomposition gas

What two factors are necessary for purge to occur?

1. There must be a substance to purge 2. There must be pressure to evacuate the material

List injuries in which the skin is Broken

Abrasion Laceration Incision Compound Fracture

Decomposition

-Bacterial and Autolytic breakdown of body tissues

What are the embalming suggestions for Alcoholism?

-Common Carotid & Femoral are good primary injection sites, unless edema is present, then use Restricted Cervical. Inject a large volume of arterial solution to compensate for the fluid lost through purge which is common in these cases. Use a moderate to strong preservative. Most require tissue building

What are Predisposing Conditions to Purge?

-Decomposition -Delay between death & embalming -Hydrothorax/Ascites -Peritonitis -Bloodstream infections -Esophageal Varices -Drowning/Asphyxia -Tissue Gas -Warm Environment -Recent abdominal, thoracic, or cranial surgery.

What are the characteristics of Gas Gangrene?

-Foul odor & infection -Strong solutions needed -Localized injection of cavity fluid

How can the pressure responsible for purge develop?

-Gas -Visceral Expansion -Arterial Solution -Ascites and Hydrothorax

How can arterial solution be a source of purge?

1. Injection of arterial solution at a faster rate of flow, especially in bodies dead for long periods, causes expansion of viscera 2. If an area of the stomach, the upper bowel, or the longness ulcerated, the arterial solution can leak through the ulcerated vessels, filled the stomach, the esophagus, or the lung tissue, and the trachea, and develop into a purge. 3. If esophageal varcies break, sufficient blood and arterial solution can exit to create purge. 4. Gastrointestinal bleeding areas can be a source of arterial solution and blood leak if there is sufficient volume and pressure during injection, anal purge results. 5. When leakage of arterial solution from an aneurysm in the thoracic or abdominal cavity develops sufficient pressure to push on the lungs or the stomach. 6. Sufficient injection pressure can cause leakage from recent surgical incisions. The arterial solution lost to the stomach or the abdominal cavity builds up enough pressure to create purge.

How does the pressure created by gas cause purge?

1. The gas in the abdominal cavity or in the hollow intestinal tract can create significant pressure on the stomach to force the contents of the stomach through the mouth or the nose. This can also push on the diaphragm with sufficient force to cause the contents of the lungs to purge through the mouth or the nose. 2. Can originate from early decomposition or from partial partial digestion of foods or maybe true tissue gas formed by Clostridium perfringens

Most species are Saprophytic and Nonpathogenic. Some found in external auditory canal, nasal sinuses, external genitalia and as secondary invaders in lung abscesses. Ear: foul moist material spotted with black granules. Lung: most common site of Series infection.

Aspergillosis

Gas gangrene follows trauma such as _________ and ________ accidents.

Automobile/Farm

What can be done to treat preembalming stomach or lung purge?

A nasal tube aspirator can be used to remove the purge from the throat and the nasal passages

What are the four forms of Histoplasmosis?

Acute pulmonary, Chronic pulmonary, Acute disseminated, Chronic disseminated.

When should you remove the gas from tissues for embalming purposes?

After embalming, not before.

What is the source of air from embalming apparatus?

Air injected by embalming machine (air pressure machines and hand pumps are in limited use today)

What are embalming suggestions for facial trauma?

Align fractures before arterial injection. Watch for glass fragments in the skin. Use a strong arterial solution

What orifice will anal purge exit?

Anal orifice

What are the embalming suggestions for gas?

Channeling of tissues after injection can release gases. Use cavity fluid to hypo localized areas of gas. Use a strong arterial solution.

What is Aspergillosis characterized by?

Characterized by abscesses, necrotic & necrotizing lesions, & sometimes chronic granulomatous inflammation.

Why do bodies who have died from renal failure rapidly decompose?

Because the acidity of the tissues leads to rupture of lysosomes, which contain the autolytic hydroenzymes that begin the decomposition cycle. The edema provides the moisture needed for the hydrolytic enzymes to act, The blood in the intestinal track provides an excellent medium for the growth of putrefactive microorganisms, The ammonia in the tissues readily neutralizes formaldehyde.

What are the contents of esophageal varices purge?

Blood Arterial solution

These bodies have a high preservative demand (6x more than normal). They decompose rapidly because they are unable to release nitrogenous wastes

Bodies who have died from renal failure

A fungus commonly found in mouth, intestinal tract, vagina of healthy people.

Candidias (Moniliasis)

Chronic Pulmonary Histoplasmosis

Progressive, forming granulomatous inflammation with caseation necrosis and cavitation. Frequently misdiagnosed as Pulmonary Tuberculosis, or may occur as secondary complication of TB. Seen most commonly in otherwise healthy males older than 40 years. Poor prognosis. Spreads through blood to other organs.

What is the source of subcutaneous emphysema?

Puncture of the lung or pleural sac (seen after CPR) Puncture wounds to thorax Rib fracture Tracheotomy

What are the embalming suggestions for an obese body?

Restricted cervical injection is recommended. Use a sheet under the body to help move the body. Large volumes of solution are needed. Use an average solution unless additional conditions warrant a stronger than average solution. When needing to inject the leg- use the more superficial external iliac, not the femoral. Purge is usually a problem

What are common conditions causing antemortem subcutaneous emphysema?

Rib fractures that puncture the pleura or a lung Puncture wounds of the thorax Thoracic surgical procedures CPR compression causing a fractured rib or sternum to puncture a lung or pleura Tracheotomy surgery

How should an Obese Body be positioned?

Shoulders should be raised High off the table Body should occupy 3 levels: head is the highest, then chest, then abdomen. Keeping head high prevents purge. Keep elbows close to body wall. Keep head straight and tie feet together. When body is in casket: tilt the shoulders and head slightly to the right.

What are the contents of stomach purge?

Stomach contents Blood Arterial solution