Discolorations Chapter 20

3 General types of Jaundice

(1) toxic jaundice, (2) hemolytic jaundice, and (3) obstructive jaundice. Within each category are a large number of diseases that bring about the antemortem discoloration.

Hemoglobin and oxyhemoglobin are blood elements, which undergo changes after death

(1)The red blood cells, which contain the hemoglobin, no longer receive a fresh supply of oxygen so their bright red color is diminished; (2)Second, those red blood cells that are oxygenated rapidly give up their oxygen as the dying cells of the body undergo for the last time the metabolic stages of anabolism and catabolism.

Discolorations Related to Embalming Chemicals: Formaldehyde Burn

In bodies dead for long periods fo time some of the capillaries in the skin may have broke. When a large volume of strong formaldehyde solution circulates through such localized skin areas-fluid can escape directly into the tissues. This can create a raised rash-like appearance.

Antemortem Blood Discolorations

Intravascular (1) Hypostasis of blood (blue-black discoloration). (2) Result of carbon monoxide (CO) poisoning (cherry red coloring). (3) Capillary congestion (hypo-static, active, or passive). Extravascular (1) Ecchymosis: a large bruise caused by escape of the blood into the tissues. (2) Purpura: flat medium-sized hemorrhage beneath the skin surface. (3) Petechia: small pinpoint skin hemorrhage. (4) Hematoma: swollen blood-filled area within the skin

Postmortem Blood Discolorations

Intravascular (1) Livor mortis. Extravascular (1) Postmortem stain. (2) Tardieu spots.

Discoloration classification by location

Intravascular (within the circulatory system) Extravascular (outside of the circulatory system). Intravascular blood discolorations either antemortem or postmortem are easily removed by arterial injection and drainage. Some extravascular discolorations may be slightly altered but most are not substantially reduced.

6 classifications of discoloration

Keep in mind the classification is by the cause of the discoloration. Thus, "ecchymosis" is a blood discoloration if caused by trauma A pathological discoloration if it occurs during a disease, Drug discoloration when brought about by a drug. Jaundice can be classified as a drug or a pathological discoloration depending on its cause: 1. Blood discolorations. 2. Drug and therapeutic discolorations (pharmaceutical agents). 3. Pathological discolorations. 4. Surface discoloring agent discolorations. 5. Reactions to embalming chemicals on the body. 6. Decomposition changes.

6 Jaundice Treatment Methods

METHOD 1: USE OF A JAUNDICE FLUID METHOD 2: USE OF A PREINJECTION SOLUTION METHOD 3: USE OF MILD ARTERIAL SOLUTION METHOD 4: USE OF CAVITY FLUIDS AS ARTERIAL FLUIDS METHOD 5: USE OF BLEACHING COINJECTION SOLUTIONS METHOD 6: USE OF THE RELATIVE COUNTERSTAINING METHOD

Nephritis

One of the signs of chronic renal failure is a "sallow yellow color" or bronzing to the skin resulting from the presence of urochrome in the tissues. This antemortem pathological discoloration takes on the appearance of mild jaundice. In cases with chronic renal failure, urea in the blood system converted to ammonia. Ammonia in the tissues and the blood acts to neutralize formaldehyde

Decomposition Discolorations

Postmortem discolorations brought about by the action of bacterial and/or autolytic enzymes on the body tissues as a result of decomposition. May be yellow, green, or blue-black to black. Examples: progressive skin color changes and "marbling" of the veins on the skin surface

Livor Mortis (Cadaveric Lividity)

Postmortem physical change and is a postmortem intravascular blood discoloration. It is brought about by gravitation of blood into the dependent capillaries. It is first observed approximately 20-30 minutes after death and is well established by the 6th hour of death Refrigeration and drugs such as blood thinners speed the onset and increase the intensity of livor mortis If the darkened area is pushed on and the area clears, this is indication that the discoloration is intravascular

Livor Mortis (Cadaveric Lividity) is

Postmortem physical change is a postmortem intravascular blood discoloration

Discolorations Related to Embalming Chemicals: Postmortem Bruising

Rare; it occurs if sufficient pressure is applied to tissues to damage the capillaries. This condition is particularly noted in persons who have been on blood thinners and in elderly people whose skin is thin.

Electrocution

Related to discoloration because of the burnt that results from contact with the electrical source. Often the palms of the hands are burned Rigor Mortis often occurs very rapidly in these deaths.

Discolorations Related to Embalming Chemicals: Flushing

Seen in those body areas into which the embalmer has been able to distribute arterial solution but has been unable to obtain good drainage of blood.

Gunshot wounds: Face and Head

Several common factors can cited with most trauma to the head or face: -Eyelids and surrounding eye tissues discolored (ecchymosis) -Eyelids and surround tissues swollen -Torn or bruised tissues easily swell during arterial injection -A majority of the bodies will be autopsied -Fractures of the facial and cranial bones pg396

Factors to consider with respect to embalming the body with post mortem stain

Several hours (approximately 6 or more) have elapsed since death. Pressed on skin does not clear. It is extravascular. It cannot be removed by arterial injection and blood drainage. It is caused by hemolysis and is not by blood in the tissues.

For all races, the color of skin has been defined as

Straw color with pink overtones

Often there is a delay between death and preparation

The intravascular condition can become an extravascular condition because of the delay. Hemolysis also occurs creating a postmortem stain. This bright red discoloration does not clear. Use a dye with the arterial solution to be certain of the distribution of the arterial fluid and to prevent the condition of formaldehyde gray.

Ecchymoses are very large discolorations. Purpura and petechiae are smaller discolorations

Very frequently, simple arterial embalming satisfactory bleaches and preserves these discolorations

Antemortem Discoloration

a. Blood discolorations b. Drug and therapeutic discolorations c. Pathological discolorations d. Surface discoloring agent discolorations

Postmortem Discoloration

a. Blood discolorations b. Surface discoloring agent discolorations c. Reactions to embalming chemicals on the body d. Decomposition discolorations

Abrasion

an antemortem injury resulting from friction of the skin against a firm object resulting in the removal of the epidermis. •Raw skin is exposed to the air and dries, it discolors to a brown color or as deep as a black color •An abrasion must be dried before restorative treatment commences. During embalming, the surrounding tissues can be protected with massage cream. • Do not apply massage cream to the abrasion. •If there is a preservation problem and fluid did not reach the abraded tissue, a surface compress of phenol cautery or cavity fluid will help promote preservation and drying of the tissues. Abraded tissue cannot be bleached with surface packs because it is dehydrated.

The discolorations caused by CO poisoning are

ante-mortem blood discolorations classified as intravascular and thus should be cleared by arterial injection.

Intravascular blood discolorations respond best to

arterial injection and blood drainage These discolorations include antemortem hypostasis of blood into the dependent tissues, cyanosis, results of CO poisoning, capillary congestion, and livor mortis

Blisters

elevations of the epidermis containing a watery liquid

Biliverdin

green discoloration

Three pigments create skin color

melanin (browns to black), carotene (yellow), and hemoglobin (oxyhemoglobin) (red). While all the three are common to all individuals and races,

What cellular elements remain in the skin after death?

melanin and carotene

Death Pallor

paleness of the skin

Special emphasis

placed on the reinstatement of the red or warm areas of the face and the hands. These are areas where the red pigment is most noticed, they include the lips, the cheeks, the base of the chin and nose, the ears, and the joints of the backs of the hand as well as any palmer surfaces that may be seen, for example, the fingertips and the sides of the thumb. This creates a natural appearance to the skin. With respect to women often an ornamental cosmetic effect is desired. Here special emphasis is placed on the color of the lips, the eyelids, and the cheeks.

Desquamation

separation of the upper layer of skin (the epidermis) from the deeper dermal layer, can be a sign of decomposition.

Formaldehyde is a chemical reducing agent

the conversion from a yellow discoloration to a green discoloration is an oxidation chemical reaction.

Discoloration

two important meanings for the embalmer. First, to discolor means "color is removed or lost." An objective of embalming is to restore lost skin color either internally by the use of arterial fluid dyes or externally by the application of a cosmetic medium to the skin surface. Second meaning is "to change color." These discolorations are further defined for the embalmer as "any abnormal color appearing in or on the dead human body." Discolorations can be localized, for example, "black-eye" or razor "burn," others, generalized, for example, livor mortis, dehydration, and jaundice.

Bilirubin

yellow discoloration

Drownings

All asphyxia deaths exhibit cyanosis due to a change in the hemoglobin; petechia in the facial tissues is common and generally the blood has a low viscosity due to the rapid death. Most noticeable discolorations are intense livor mortis, petechia, and possibly cyanosis.

Ecchymosis, purpura, and petechia

All extravascular. •Classified as blood discolorations but can also be classified as pathological and drug discolorations. •Can be caused by diseases as well as by extended use of many pharmaceutical and chemotherapeutic agents. •Treatment of these extravascular conditions can involve all three types of embalming: arterial, hypodermic, and surface.

Discolorations Related to Embalming Chemicals: Dehydration

Drying on the skin The classic colors of this discoloration are yellow, brown, and black. Dehydration can be caused internally by injection of too much arterial solution, use of an arterial solution that is too strong, and continuous or concurrent drainage. It can also be causes externally by the passage of air over the body.

Exsanguination

Excessive loss of blood to the point of death

Restoration of the visible skin areas to a natural color and acceptable appearance involves the

Fluid dyes and arterial injection and drainage

Skin lesions

• is any traumatic or pathological change in the structureterm-49 of the skin. • The objective of the embalmer is to properly sanitize skin lesions, clean them of debris, remove skin that cannot be used in the restorative treatment, and secure adequate preservation and drying of the tissues. •There are four categories of skin lesions: (1) unbroken skin but discolored (2) skin scaling as in exanthematous diseases (3) skin that is broken or separated from the body (4) pustular or ulcerative lesions.

Burned bodies

•Burns may be caused by heat (thermal burns), electrical shock, radioactive agents, or chemical agents. •It is not always the local effect of the burn that should concern the embalmer, but rather the systemic effects brought about by major burns: Bacterial infections, lack of blood flow to peripheral areas of the body, and kidney failure and the resulting buildup of wastes in blood and tissue fluids

Pathological Discolorations Antemortem

1. Gangrene a. Wet: caused by venous obstruction; infected tissues red to black in color b. Dry: caused by arterial insufficiency; a dark red-brown to black color When gangrene occurs in a facial area or affects the fingers Frostbite and diabetes can be responsible for this condition in the facial areas and the hands. Arterial preservation is difficult to establish, and surface and hypodermic preservation are necessary. 3. Specific diseases a. Addison's disease: a bronze discoloration produced in the skin b. Leukemia: petechiae c. Meningitis: discolorations can include cyanosis; a blotchy erythematous rash (reddening) of the skin; petechia and purpura d. Tumors: discolorations in and around the tumor itself may be caused by pathological changes e. Lupus erythematosus: a chronic skin disease characterized by scaling, red, macular rash

Embalmer Concerns with Livor Mortis

1. It is a postmortem physical change. 2. It appears in dependent tissues. 3. It is speeded by refrigeration and blood thinners, CO deaths, low blood viscosity, and large blood volume. 4. It is an intravascular condition. 5. It may be cleared by arterial injection and blood drainage. 6. It may be gravitated and massaged from a body region. 7. Color varies from light pink to almost black depending on blood volume and viscosity. 8. When pushed on (or palpated), tissues clear. 9. It is cleared best by the use of mild arterial solutions or preinjection solutions.

Discolorations Related to Embalming Chemicals: Embalmer's (formaldehyde) Gray

A graying of the tissues, is due to failure of the embalmer to remove as much of the blood out of the body as possible. The remaining blood mixes with the preservation fluids in the tissues, and the resulting color is dark gray.

Embalming

A process that chemically treats the dead human body to reduce the presence and growth of microorganisms, to retard organic decomposition, and to restore an acceptable appearance of the body.

Postmortem Hypostasis

Blood begins to drain from upper areas of the body into the dependent vessels Hypostasis can begin even before death in which is described as the agonal phase of dying

Two postmortem conditions, which are not causes of death, but have a relationship to discolorations, are also included here:

Bodies refrigerated prior to embalming and mold

CO Poisoning

Cherry-red appearance of skin The bright color of the blood is due to carboxyhemoglobin, a component of blood. The bright reddish color is found in the dependent areas of the body to which the blood gravitates after death- the areas where Livor Mortis is present. This discoloration is classified as an antemortem intravascular blood discoloration

Skin

Defined as the organ that forms the outer surface of the human body. It consists of two major divisions, the superficial epidermis and a deeper dermis

Extravascular Blood Discoloration

•Extravascular blood discolorations do not respond well to arterial treatment. •Examples of these discolorations are ecchymosis, purpura, petechia, hematoma, and postmortem stain and Tardieu spots. •Injection of a stronger arterial solution assists in bleaching some of these discolorations. Both livor mortis and postmortem stain can be present in the same dependent area. The livor might be "washed out" but the stain remains. •Preinjection, coinjection, or "special arterial" fluids cannot completely remove these extravascular discolorations. When formaldehyde reacts with these discolorations, they usually turn gray in color.

Burns classified into 3 categories

•First degree: The skin surface is red (erythema); only the surface epithelium is involved •Second degree: The skin blisters and edema is present. Blisters beneath or within the epidermis are called bullae. There is destruction of the deep layers of the epidermis and the upper layers of the dermis •Third degree: The tissues are charred. The epidermis, the dermis, and epidermal derivatives such as hair follicles and glandular inclusions are destroyed

Jaundice

•Healthy human blood serum contains approximately 1.0 to 1.5 mg of the bile pigment bilirubin (which is yellow in color) per 100 mL as a result of the breakdown of red blood cells. • Most red blood cells live approximately for 120 days. Because of a variety of diseases that result in hepatic failure, excessive blood hemolysis, or obstruction of the contents of the gallbladder, the level of bilirubin reaches above 1.5 mg per 100 mL of blood serum and the tissues of the body begin to take on the yellow jaundiced condition

Pharmaceutical Discolorations

•Pharmaceutical, drug, or chemotherapeutic discolorations occur from the administration of these agents. These discolorations are all antemortem. •Extravascular pathological discolorations such as ecchymosis and purpura should be treated using those embalming treatments for extravascular blood discolorations.

Post Mortem Stain Solution

•Stronger arterial solution needs to be used in the embalming of bodies with this condition. Circulation may be difficult to establish. There is also a tendency for these bodies to easily swell. The embalming solution used should be of sufficient strength so that a minimum volume effects preservation but at the same time minimizes distension. •Some dye should be added to this solution, because when the formaldehyde and the coloring portion of the blood mix to produce a gray hue, the extra dye not only indicates surface distribution of the fluid but also acts to counterstain the adverse discoloration. •Avoid using preinjection solutions in the preparation of these bodies. Bodies dead for long periods require strong, well-coordinated solutions. A preinjection treatment would only fill the vascular system with a weak, non-preservative solution

Surface Discoloring Agent

•Surface discoloring agents are antemortem or postmortem discolorations. • Examples include blood, betadine, adhesive tape marks, gentian violet, paint, mercurochrome, and tobacco tars. •Most of these can easily be removed with soap and water or with a solvent such as the dry hair washes •Mechanical and chemical methods can be used to remove surface discoloring matter.

Decomposition is evidenced by 5 signs: Odor, desquamation, gas, purge, and color change

•The first external sign of decomposition is a color change, usually a green discoloration of the right inguinal or iliac area of the abdomen. •A color change is also evidenced throughout the skeletal tissues. Generally, the color changes from yellow to green to blue-black to black. •In addition, the blood in the veins begins to break down. This discoloration progresses from the red of the postmortem stain to a black and follows the course of the vein. •The pattern thus forms a "spider-web" and the veins are described as being marbled.

Preservation takes precedence over clearing of the discoloration (Jaundice)

•The new non-formaldehyde fluids are proving to be beneficial in the clearing of jaundice. Using restricted cervical injection these fluids could be used for injection of the head and face. •Standard preservatives could be used for the remainder of the body. •Preservation is most important in the preparation of a jaundiced body. These bodies can always be treated with opaque cosmetics to successfully hide the discoloration. A good foundation even for cosmetic treatment is good preservation.

Tardieu spots

•are pinpoint hemorrhages seen in the areas of advanced livor mortis. •The skin capillaries have burst, thus causing the pinpoint hemorrhages into the skin. • Extravascular condition and the dark spots cannot be removed by arterial injection and blood drainage.

Postmortem Stain

•stain (a postmortem chemical change) is an extravascular blood discoloration. • Occurs in tissues where livor mortis was present or in surface tissues from which blood could not be drained. •Stain usually indicates a time has elapsed between death and embalming (Postmortem Interval). •Decomposition or breakdown of the red blood cells. The coloring matter (heme) has moved through the capillaries and into the tissue spaces. •Postmortem stain can occur along with livor mortis in the same tissue regions. When pressed upon (or palpated), the skin does not clear. During arterial injection the discolored area will lighten but not entirely clear.