EMBALMING II

INDICATORS OF ARTERIAL SOLUTION DISTRIBUTION

- A drop in the volume of solution in the tank. - There is differential pressure. - Drainage is occurring.

RE-ASPRIATION & RE-INJECTION

1. A noticeable amount of gas escapes when the trocar button is removed. 2. The body is to be transported to another funeral home. 3. Final disposition is to be delayed. 4. Decomp is evident prior to embalming. 5. Abdominal surgery has been performed recently. 6. The body is obese. 7. The body shows evidence of gas. 8. Death was due to a blood infection or infectious disease. 9. Death was due to drowning, or purge was evident prior to, during, or after embalming. 10. Ascites (accumulation of serous fluids in the peritoneal (abdominal) cavity) is present.

DRAINAGE - METHODS

1. Alternate- Arterial fluid is being introduced while drainage is shut. Then injection of fluid stops and the drainage is open. Then the drainage is stopped and injection occurs again. And on and on. 2. Concurrent- AKA Continuous. Both injection and drainage is taking place at the same time. You will use this method 99% of the time. 3. Intermittent- Continue injecting when the drainage is stopped and started periodically. The most important thing about drainage to remember is as soon as you see distension, STOP injecting, that means you are not getting enough drainage.

AUTOPSIED BODY - ORDER FOR PREPARATION

1. Unwrap, disinfect, and relieve rigor mortis present in the body. 2. Shave the face (with permission of course) and set the features. 3. Open the cavities and remove the viscera. 4. Place the ligatures around the carotid, axillary, and iliac arteries. 5. Prepare the solution after doing a pre-embalming analysis. 6. Inject the legs first, then the arms, then the head (left side first). 7. Perform any supplemental treatments by hypo-ing. 8. Drain all the liquid from the body cavities and treat with hardening compound or autopsy gel. 9. Return the bag of viscera if available or fill with the sheeting. 10. Suture the thoracic and abdominal cavities. 11. Dry the cranial cavity and paint it with autopsy gel. 12. Suture the scalp. 13. Wash and dry the body. 14. Apply glue to the incisions of the thoracic and abdominal cavities. 15. Prepare the embalming report.

5 FACTORS DETERMINED IN EMBALMING PROCESS

1. Vessels for injection and drainage 2. Strength of the embalming solution 3. Volume of the embalming solution 4. Injection pressure 5. Injection rate of flow

ORGAN

An organ is defined as any part of the body exercising a specific function such as respiration, secretion, and digestion.

HYDROASPIRATOR - CAVITY EMBALMING

Apparatus that is connected to the water supply. When the water is turned on, suction is developed and is used to aspirate the contents of the body's cavities. If a hydroaspirator is clogged, it will reverse the suction and water will enter into the body cavity. This is a bad situation because we know that water encourages decomposition. Check your hydroaspirator frequently for material, and "flush" it often. This can be accomplished by placing the tip of the trocar into the sink and then reversing the suction allowing the water to push out any clogging materials. Adipose material is a usual culprit in clogging the trocar. The hydroaspirator is used in probably 99% of all preparation rooms.

EMBALMING - OVER 75 YEAR OLDS (ELDERLY)

Arthritis conditions- this creates positioning problems. The use of head block can help. Don't cut anything and don't break anything. If the family is used to seeing the person in the fetal position they won't be surprised to see them that way in the casket! Mouth Closure- It can be hard to use the needle injector because of atrophied muscles and a weakened mandible/maxilla. The mandibular suture is recommended when suturing.

EMBALMING REPORT

As important as the embalming is, the condition of the body needs to be noted BEFORE any process begins. If you ever go into court your best defenses will come from how the body appeared before the embalming started.

INTRAVASCULAR RESISTANCE

Can be caused by: narrowing or obstruction of the lumen of a vessel. • Obstructions include: blood, antemortem emboli, antemortem throbi, and postmortem coagula and thrombi. • Narrowing is usually caused by arteriosclerosis, vasoconstriction, arteritis, and intravascular rigor mortis.

CAVITY EMBALMING - WHAT IS IT?

Cavity embalming has been practiced in some form or another since the Ancient Egyptian period. Cavity embalming as we know it today didn't come into practice until the end of the 19th century. Cavity treatment is a two-step process and includes: Aspiration of the cavities and their contents and Injection of a strong preservative/disinfectant chemical. The challenge of cavity embalming is: it is NOT a visible process. In other words, you can't see the inside of the cavity to tell what you're doing. Cavity embalming treats: The contents of the hollow portions of the viscera, the walls of the visceral organs not embalmed by arterial injection, and the contents of the spaces between the visceral organs and the walls of the cavities. The materials that are aspirated include: Odor Gas formation Purge Solid materials such as: Blood Fecal material Undigested food

PURGE PREVENTION

Certainly the best way to prevent purge is by packing ALL of the orifices. In many areas of the south this even includes packing cotton in the ears, as this can be a place of entry for bugs.

POST EMBALMING TREATMENTS

Check and re-check a body lying in state. Check for: dehydration of the tissues purge any type of leakage softening and discoloration of the tissues gas formation separation of the lips and eyelids odors cosmetic changes Cleaning under the fingernails Making sure the clothing is clean and pressed Rinsing the fluid bottles three times so they can be placed in the regular trash Doing the laundry

COMPLETE AUTOPSY

Complete Autopsy includes all of the following: 1. Cranial Cavity 2. Eye Enucleation 3. Removal of neck organs 4. Thoracic cavity 5. Abdominal cavity 6. Pelvic cavity 7. Removal or sample of spinal cord (NOTE: What a pathologist takes from these cavities varies greatly.)

CAVITY CHEMICAL INJECTION

Concentrated cavity fluid is always used, never add water. How much cavity fluid should be used? Many funeral homes have their own policy. It could be one of three: Each body will only get 1 bottle (16 ounces) of cavity fluid. Eight ounces in the thoracic cavity, and 8 ounces in the abdominal and pelvic cavities. Each body will get 2 bottles (32 ounces) of cavity fluid. Sixteen ounces in the thoracic cavity, and 16 ounces in the abdominal and pelvic cavities. Each body should have as many bottles as it takes/needs. My personal preference is the last one. I have embalmed elderly women that maybe weighed 125 pounds and could only hold one bottle without leaking it. I have also embalmed 300 pound people that needed 3 bottles. I think that the body should dictate what amount should be used.

INTRAVASCULAR SOLUTIONS

Intravascular Resistance is a problem because the embalmer doesn't usually know where the resistance is coming from. • The tendency is to use more pressure to push the resistance through. Although this is a method to be used it needs to be noted that swelling is a concern. • Use the right common carotid artery for injection; this will help push the coagula away from the arteries that supply the head and arms. • Avoid using a sclerotic artery. An embalmer can usually tell before cutting an artery if it's sclerotic. Try raising another artery before injecting a sclerotic artery. • Use the largest artery possible for the primary injection point. This helps in part because if you do have to inject a sclerotic artery, a smaller arterial tube can be used to help bypass the sclerosis. • Don't damage the artery by forcing an arterial tube that is too large.

CLOSURE OF INCISIONS

Linen thread is stronger than cotton. Dental floss is a good alternative thread for visible areas such as cranial autopsy incisions. Pull on the THREAD and not the needle to tighten the suture. A 3/8 inch circle needle is used for restorative sutures and to suture incisions made to raise vessels. A double curved autopsy needle is used to close autopsy incisions, surgical incisions, and incisions made to raise vessels. Types of Sutures Baseball Single Intradermal (Hidden) Double Intradermal Inversion (Worm) Interlocking (Lock) Continuous (Whip)

LONG BONE DONOR (FEMUR, TIBIA, FIBULA, HEMIPELVIS)

Lone bone procurement is the most dramatic of all tissue recovery. There is a large disruption of the circulatory system. These cases should not be pre-injected. Your book describes a method of embalming where the sutures of the leg are not open. I can't imagine doing this. Here in Denver when long bone donation takes place we basically get the skin of the legs and that's it, there's nothing to inject. The legs are skin and attach at the top to the buttocks and the bottom to the feet but there wouldn't be anything to arterially embalm. We simply hypodermically inject what we can and then sprinkle embalming powder (sometime called vis-a-rock) in the legs and then sew them back up tightly. Depending on what has been taken sometimes the iliac artery will be exposed and be used to inject toward the body so that an incision to raise the carotid is not necessary. In other cases the carotid must be raised.

AUTOPSY - TYPES

Medical or Hospital Autopsy These are mostly done at teaching hospitals. Permission must be received by the family. Many times it is used to remove just one or two organs. Coroner or Medical Examiner Autopsy The goal is to determine the cause and manner of death. The reasons for a coroner autopsy vary from state to state.

CARDIAC DISEASE

Moderate to strong fluid should be used Dyes can help locate where the fluid has reached.

INJECTION TECHNIQUES - TYPES OF INJECTION

One-point; injection and drainage from one site. Split injection/drainage; injection from one site and drainage from another Multi-point; injection at two or more sites. Restricted Cervical; injection of both common carotid arteries. Six-point injection; injection of the right and left common carotid, axillary, and femoral arteries. In an autopsy case the subclavian or brachial arteries can be used for the arms; and the common (internal) or external iliac arteries can be used for the legs.

PRESSURE

Pressure is an important part of the process because the pressure is what helps force out the blood. • The pressure needed to force the solution through the arteries decreases by the time solution reaches the capillaries.

STOPCOCK

RATE OF FLOW VALVE

TREATMENT OF DISTENTION

Swelling present prior to arterial embalming should be noted on the embalming report. Examples include: Edema Tumors Swelling caused by trauma Distention from gases of decomposition in the tissues or cavities Tissue gas produced by clostridium perfringens Distension caused by allergic reactions Distension brought about by use of steroid drugs Gases in the tissues from subcutaneous emphysema Distension caused by too rapid injection of the arterial fluid

UAGA - UNIFORM ANATOMICAL GIFT ACT

The Uniform Anatomical Gift Act allows any person aged 18 years or older to donate any or all of their organs and tissue for transplantation, research, or educational purposes after his/her death.

WASHING & DRYING OF THE BODY

The area most neglected is the back, because it's the hardest to wash and dry. It is also important that the back is dried well to prevent the growth of mold. Figure 15-8 on page 301 of the text shows plastic protecting the hand of the deceased for dressing and casketing. An alternative would be to wait to cosmetize the hands after dressing and casketing. Simply place a towel under the hands in the casket and carefully cosmetize the hands.

RETAINED EMBALMING SOLUTION

The arterial solution that is not discharged through the vascular system as drainage but remains in the body to embalm it is called retained embalming solution. As little as 50% of the embalming solution actually remains in the body to complete the embalming process.

AUTOPSY CLOSURE OF CAVITIES

The baseball stitch is the most secure stitch and is recommended. DON'T FORGET TO PUT THE BREASTPLATE BACK ON! I watched an embalmer do this once, he finished sewing and then turned around, and there was the breastplate on the counter. Needless to say, he had a long night. Pull on the thread, not the needle. Pulling on the needle will make larger holes in the skin. Bring all three flaps together and suture them into one point. Then start from the lowest part of the "Y", and then each branch can be completed from the high point of the bottom of the "Y" and then to the shoulders. Use adequate amounts of incision seal powder.

ORGAN DONATION CONSENT

The consent for the organ donation comes from the next-of-kin in the following order as outlined in the Act: 1. spouse 2. adult son or daughter 3. either parent 4. adult siblings 5. guardian 6. any other person authorized to do so (i.e., an executor of a will) The next of kin are allowed to give consent for specific organs and not others. Gifting organs does not mean they will necessarily be able to be used.

ENUCLEATED EYEBALLS

The entire eyeball is removed. The embalmer's concern is this type of case would be swelling or distention in or around the orbital cavity. There is also a potential concern for bruising and small lacerations. The following is recommended for embalming a case where eye enucleation has taken place: 1. use restricted cervical injection 2. avoid pre-injection procedures 3. use a slightly stronger than average arterial solution 4. touch the eyelid as little as possible 5. allow the embalming solution to drain on its own from the eye during the injection (in other words, don't try to "squeeze" it out) 6. use a lower rate of flow and injection pressure during the arterial injection

TISSUE DONORS

The most commonly transplanted tissue is the cornea. The cornea itself can be removed for transplant, but if the entire eyeball is removed it is termed enucleated. The embalmer's concern is this type of case would be swelling or distention in or around the orbital cavity. There is also a potential concern for bruising and small lacerations.

ASPIRATION TECHNIQUE

The point of entry is 2 inches to the left and 2 inches above the belly button. This is the only puncture that needs to be made to reach all of the cavities. The order of cavity aspiration should be: Thoracic Abdominal Pelvic The reason is you don't want to take microbes from the colon in the pelvic cavity and then later deposit them in the thoracic cavity. It's like cleaning dishes- you clean the glasses first when the water is clean, and the pots and pans last when the water is already dirty. After the thoracic cavity is aspirated the trocar must be removed and turned around to aspirate the abdominal and pelvic cavities.

PLASTIC GARMENTS

The unionalls cover the arms, trunk, and legs. Sleeves cover a single limb.

THORACIC AUTOPSY

Thoracic- one or more organs are usually removed. The most practical and thorough embalming method is: Always embalm the arms and head separately. Next raise the right femoral artery and inject the leg first and then toward the abdomen. Ligate any leaking vessels in the cavity. After embalming hypo inject the walls and shoulders as needed and then paint the cavity with autopsy gel.

MACHINE INJECTION - CAVITY FLUID INJECTION

Three bottles of cavity fluid are placed in the tank of the embalming machine. The delivery hose is connected directly to the trocar. The pressure and rate of flow should both be set very low. Cavity fluid really dries out the seals and hoses.

AMPUTATIONS & GANGRENE

Treat by hypo-ing

DECUBITUS ULCERS

Treat with a cotton compress with cavity fluid and or hypo-ing

TUBING - CAVITY EMBALMING

Try to use clear tubing instead of rubber tubing. The clear tubing will allow you to see what is being aspirated as well as the quantity. They are usually 3/8 to ½ inch in diameter. Make sure you always have extra tubing on hand since you will want to replace it as soon as you see the signs of wear and cracking.

TROCAR - CAVITY EMBALMING

a long hollow needle (metal tube) with a removable sharp point. It is used to pierce the wall of the abdomen and the walls of the internal organs. It is attached to the hydroaspirator to withdraw the contents of the cavities, and it is also used to inject cavity fluid. A trocar is about 18 in. long and 5/16 in. in diameter. An infant trocar is about 12 inches long and ¼ in. in diameter. It is used for cavity treatment for infants and children. It can also be used for hypodermic injection. A TROCAR MUST BE DISINFECTED PROPERLY. Trocar's can carry tuberculosis and tissue gas from one body to the next. Since tuberculosis is transmitted through the air this can also be of concern to the embalmer. Don't assume that because cavity fluid went through the trunk of a trocar that it is clean. It still needs to be disinfected.

FETUS

a pre-term baby weighing less than 5 ½ pounds or born before week 37.

DRAINAGE

can include: - blood (including clots), - embalming solution, - interstitial fluid (fluid in the tissues), and - lymphatic fluid.

EXTERNAL APPROACH/ACCESS

external access, and example of this is raising the common carotid artery as in a normal unautopsied case.

INTERNAL APPROACH/ACCESS

internal access, an example of this is to open the leg where long bone donation has taken place and use the femoral that is exposed from the harvesting and inject toward the trunk.

TISSUE

is defined as a collection of similar cells and the intercellular substances surrounding them.

INJECTION PRESSURE

is the amount of pressure produced by an injection device to overcome initial resistance within the vascular system.

CRANIAL AUTOPSY

Cranial- the brain is usually removed. Embalming methods include: Arterial tubes are inserted in both right and left common carotids toward the face and one tube directed toward the body from the right common carotid. The right jugular vein is used for drainage. Inject down first, and then inject the left and right sides of the head. Raise the right common carotid artery and insert arterial tubes both toward the head and toward the body. Inject down first, and then up. Clamp off any leaking vessels inside the cranial cavity. Use the femoral vein and artery. Inject the leg first and then inject upwards. Clamp off the leaking vessels in the cranium during injection. Then dry the cranial cavity, paint it with autopsy gel and fill it with cotton. After the embalming is complete, attach the calvarium and suture the scalp back into position. Remember to suture from right to left and the use of dental floss for ligature can give a better overall look.

EMBALMING PROCESS - 4 PARTS

Delivery- of the fluid from the machine through the arterial tube and into the artery. • Distribution- the movement of the fluid into the arterial system and into the capillaries. • Diffusion- movement of the arterial solution intravascular to extravascular by way of the capillary walls. • Drainage- can include: - blood (including clots), - embalming solution, - interstitial fluid (fluid in the tissues), and -lymphatic fluid.

SHIP-OUTS

Don't glue the lips. Remember to include a copy of the embalming report as a courtesy to the receiving funeral home.

DRAINAGE

Drainage consists of: Blood, Interstitial fluid, Embalming solution, and Lymphatic fluid. It has been estimated that 50% or more of the drainage occurring during embalming is actually from embalming solution. As long as the solution is distributing and there is no swelling or discolorations in the tissues, drainage is not a concern. Coagula in the arterial system can easily be pushed into minute arterial tributaries; this is what allows drainage to occur.

AUTOPSY - DRAINAGE

Drainage in an autopsy is taken directly from the cut vein. There is no need for any type of drainage tube to be used. Drainage is aspirated by the use of an autopsy aspirator that is constantly on during the embalming.

INJECTION & DRAINAGE TECHNIQUES

During the embalming of the body, four processes take place at the same time. They are: 1. Injection (also referred to as Delivery in Chapter 13) 2. Distribution 3. Diffusion 4. Drainage

MANDIBLE DONORS

Embalmers have not developed a technique to allow for viewing when the mandible has been taken. Because of this the goal of embalming is strictly for preservation and not restoration. Your book does not actually discuss the embalming process for these cases. You will inject any arteries that are exposed that can be injected, hypodermically embalm where needed, and finally paint autopsy gel on the skin and cover the head with a bag so that the formaldehyde fumes can be "trapped" in the bag to allow the embalming to take place.

PROXIMAL HUMEROUS AND SCAPULA DONORS

Embalming is done with little to no disruption of the blood vascular system.

EXTRAVASCULAR RESISTANCE

Extravascular resistance is easier to deal with because it is caused by conditions that when using specific techniques the resistance can be lessened. • Rigor Mortis- massage and manipulation can clear this extravascular resistance. • Gas in the Cavities- Use a trocar to relieve the pressure. (I wouldn't cut the intestines as the book suggests.) • Expansion of the hollow viscera during injection- if this occurs a trocar can be used to relieve the pressure. • Tumors and Swollen Lymph nodes- several techniques can be tried. Sectional injection, using higher injection pressure, pulsation, massage and manipulation. The technique used should in part be determined by the location of the tumor or lymph node. • Ascites and Hydrothorax- Several drainage sites should be used. • Contact Pressure- The areas that lay on the table usually don't receive enough fluid. Massage of these areas is important. • Visceral Weight- In obese bodies massage, manipulation, higher pressure, pulsation, and a more rapid rate of flow may be needed to overcome the resistance. • Bandages- Any elastic bandage or bandage wrapped around an extremity should be removed prior to injection. (This includes hospital i.d if on too tight. They can cause resistance by keeping fluid from getting into the hands.) • Skeletal Edema- Higher injection pressure, pulsation, manipulation, massage, and section embalming may help. • Inflammation- Higher injection pressure, pulsation, massage, sectional and hypodermic embalming may be necessary.

MALIGNANCY

Fluid strength should be moderate to strong A co-injection can help

EMBALMING - ADDITIONAL POINTS TO REMEMBER

Fluids follow the path of least resistance Embalming in which only the skin and superficial portions of the body receive solutions is referred to as shell embalming. Coagula in the arterial system can easily be pushed into minute arterial tributaries; this is what allows drainage to occur.

GRAVITY INJECTOR - INJECTING CAVITY FLUID

Gravity injector- most funeral homes use this method. A hose connects the injector to the trocar. The higher the bottle is raised the faster the fluid flows into the body. By placing a finger over the hole in the injector the embalmer stops the flow of cavity fluid.

TEMPORAL BONE DONORS

If the internal approach has been used to recover the temporal bone there should be no disruptions with the embalming. If the external approach has been used to recover the temporal bone then the upper portion of the face and eyes may not receive sufficient amounts of arterial solution. The embalmer should use dye as a tracer in these cases.

MULTI POINT INJECTION

Injection at two or more sites. This may be used in the following cases: 1. When a body area does not receive or needs more arterial solution 2. Bodies dead for a long time 3. Signs of decomposition are evident 4. Death by ruptures aortic aneurysm (the fluid will simply fill the cavity instead of going through the arterial system) 5. Highly contagious diseases 6. Delayed viewing or disposition 7. Military or shipping requirements 8. Purge develops and/or drainage stops 9. Generalized edema 10. Difficulty firming 11. Poor peripheral circulation 12. True tissue gas 13. Autopsied 14. Organ and/or tissue donation

RESTRICTED CERVICAL

Injection of both common carotid arteries. This may be used in the following cases: 1. Facial trauma 2. Facial distension is anticipated 3. Eye enucleation 4. Generalized edema 5. Difficulty firming 6. Distribution Problems 7. High HCHO demand 8. Purge is anticipated 9. Jaundice is present

INSTANT TISSUE FIXATION

Instant tissue fixation refers to an embalming technique that uses restricted cervical injection in order to treat the head with a small amount of very strong arterial solution. The goal is to immediately preserve, dry and firm the tissues. It is used when: Decomposition on the face has started. Facial trauma is present. A dry and firm surface is needed for restorative treatment. Facial excisions are necessary as in the case of cancer. NOT when re-embalming the face at the book suggests.

INTRAVASCULAR PRESSURE

Intravascular Pressure (IVP) is caused by the pressure from the machine and expansion of the arteries. This pressure forces the solution through the walls of the capillaries therefore embalming the body. • Although the pressure helps discharge fluids, generally the amount is one half or less the total volume of arterial solution used.

AUTOPSY

ALTERNATE NAMES FOR AN AUTOPSY NECROPSY POSTMORTEM

SUPPLEMENTAL EMBALMING TREATMENTS

Surface embalming with the use of liquids, gels, or powders Hypodermic embalming with the use of a hypodermic syringe and needle

ABDOMINAL AUTOPSY

Abdominal-Usually the contents of the cavity are removed. The most practical and through embalming method is: Inject downward from the right common carotid artery and then upward toward the head. Clamp off any leaking areas. The iliac arteries will be present in the cavity and can be used for injection of the legs. The abdominal cavity should be painted with autopsy gel and filled with sheeting.

WORK & ENGINEERING CONTROLS

Adequate ventilation system Prevent chemical spills Keep embalming machine in good repair Rinse fluid bottles Cap all chemical bottles Keep a lid on the embalming machine Clamp all leaky vessels during embalming Restrict drainage Use closed drainage Cover the sink to avoid splashing Keep a water hose on the table to flush away drainage Avoid high water pressure

AUTOPSY - TREATMENT OF THE VISCERA

Always use a new bag to treat the viscera. Pour at least 2 bottles of cavity fluid over the viscera after cutting the viscera to let any gases escape. It should always be returned to the cavity. Remember this- if it all fit in there when the person was alive, then it should all fit in there when they're dead. I reject the idea that it won't fit.

PARTIAL AUTOPSY

1. Cranial- the brain is usually removed. Embalming methods include: Arterial tubes are inserted in both right and left common carotids toward the face and one tube directed toward the body from the right common carotid. The right jugular vein is used for drainage. Inject down first, and then inject the left and right sides of the head. Raise the right common carotid artery and insert arterial tubes both toward the head and toward the body. Inject down first, and then up. Clamp off any leaking vessels inside the cranial cavity. Use the femoral vein and artery. Inject the leg first and then inject upwards. Clamp off the leaking vessels in the cranium during injection. Then dry the cranial cavity, paint it with autopsy gel and fill it with cotton. After the embalming is complete, attach the calvarium and suture the scalp back into position. Remember to suture from right to left and the use of dental floss for ligature can give a better overall look. 2. Thoracic- one or more organs are usually removed. The most practical and thorough embalming method is: Always embalm the arms and head separately. Next raise the right femoral artery and inject the leg first and then toward the abdomen. Ligate any leaking vessels in the cavity. After embalming hypo inject the walls and shoulders as needed and then paint the cavity with autopsy gel. 3. Abdominal-Usually the contents of the cavity are removed. The most practical and through embalming method is: Inject downward from the right common carotid artery and then upward toward the head. Clamp off any leaking areas. The iliac arteries will be present in the cavity and can be used for injection of the legs. The abdominal cavity should be painted with autopsy gel and filled with sheeting.

DRAINAGE - PURPOSE

1. Make room for arterial solution. 2. Reduce secondary dilution of the arterial solution. 3. Remove intravascular blood discolorations. 4. Remove blood to keep it from decomposing. 5. Remove bacteria. 6. Prevent discolorations. 7. Reduce swollen tissues. The center of drainage is the right atrium of the heart, that's why the drainage instrument used is always directed toward the heart. A broken vein can still be used for drainage but it's pretty darn hard to find the ends of it and tie it off as the book suggests. If you try that direct heart drainage as the book suggests and do it wrong, you've just messed up the entire circulatory system. DON'T DO IT!!!! It's also called a heart tap.

HOW TO PICK AN ARTERY

1. Size 2. Can I use the accompanying vein for drainage 3. Depth of location 4. Flexibility 5. Effects on Posing the body 6. Potential leakage consideration 7. Proximity of the vessel to the arch of the aorta

HOW TO PICK A VEIN

1. Size 2. Proximity to the right atrium of the heart 3. Blood discolorations of the face and neck 4. Flexibility 5. Depth

STILLBORN

a fetus that dies prior to delivery (in Colorado a stillborn is after 26 weeks gestation and requires a fetal death certificate and permit for disposition).

ORGAN DONORS

1. assess the situation to determine which organs have been harvested. 2. analyze the embalming complications, for example, the femoral artery cannot be used to inject downward if long-bone donation has taken place, but it may be used to inject toward the trunk of the body 3. develop a plan for the application of embalming treatments 4. implement the embalming plan 5. engage in concurrent evaluation of the effectiveness of the embalming treatments, making any changes in procedure that might be indicated There are two options for arterially embalming an organ donor: 1. external access, and example of this is raising the common carotid artery as in a normal unautopsied case. 2. internal access, an example of this is to open the leg where long bone donation has taken place and use the femoral that is exposed from the harvesting and inject toward the trunk. Keys to successful autopsy and organ donor embalming include: 1. knowing anatomical structures and relationships 2. anticipating which vessels have been cut, and 3. an ability to locate the end of the vessels which have been cut

NASAL ASPIRATOR - CAVITY EMBALMING

A 10-inch, 90 degree curved metal tube used for aspiration of the nasal/oral cavity. It clogs very easily.

REMOVAL OF BODY INVASIVE DEVICES

A pacemaker only has to be removed when cremation is taking place. The incision does not need to be sutured as the body is going to be cremated. If the family is having a viewing or an identification of the deceased then wait to remove the pacemaker until that is over. Intravenous needles or tubes are taken out after arterial injection. Colostomy openings may be closed before or after arterial injection.

SENILE PURPURE (ECCHYMOSIS)

A slower rate of flow will help remove the discoloration Remove any loose skin before embalming Leakage is a problem so take precautions

CLOSING THE INCISION

A trocar button- probably the most commonly used method. A purse-string suture. An "N" suture. The benefit of the trocar button is it is easy to use. The benefit of the sutures is that they close the incision more completely.

TODDLER

AGE 18-48 MONTHS

INFANT

AGE BIRTH TO 18 MONTHS

ABDOMEN - 9 DIFFERENT REGIONS OF THE ABDOMEN & THEIR CONTENTS - ABDOMINAL ANATOMICAL REGIONS

RIGHT HYPOCHONDRIAC - UPPER REGION Part of the liver Part of right kidney Greater omentum Coils of small intestine Gallbladder EPIGASTRIC - UPPER REGION Stomach Portion of liver Duodenum, Pancreas Suprarenal glands and parts of kidney Greater omentum LEFT HYPOCONDRIAC - UPPER REGION Part of liver Stomach, fundus, and cardiac regions Spleen Tail of pancreas Part of left kidney RIGHT LUMBAR - MIDDLE REGION Lower portion of liver Ascending colon Part of right kidney Coils of small intestine Greater omentum UMBILICAL - MIDDLE REGION Transverse colon Parts of kidneys Part of duodenum Coils of small intestine Greater omentum Bifurcation of the abdominal aorta and inferior vena cava LEFT LUMBAR - MIDDLE REGION Part of left kidney Descending colon Coils of small intestine Greater Omentum RIGHT INGUINAL (ILIAC) - LOWER REGION Cecum, appendix Part of ascending colon Coils of small intestine Greater omentum HYPOGASTRIC - LOWER REGION Bladder in adults Uterus during pregnancy Coils of small intestine Greater omentum LEFT INGUINAL (ILIAC) - LOWER REGION Part of descending colon Sigmoid colon Coils of small intestine Greater omentum

ABDOMINAL QUADRANTS

Right Upper Quadrant (RUQ) Left Upper Quadrant (LUQ) Right Lower Quadrant (RLQ) Left Lower Quadrant (LLQ)

TROCAR GUIDES

S, Stomach; Upper left quadrant C, Cecum; Right Lower Quadrant UB, urinary bladder; H, Heart; Right upper quadrant X, Insertion point. The point of entry is 2 inches to the left and 2 inches above the belly button.

POST EMBALMING TREATMENTS

SUPPLEMENTAL EMBALMING TREATMENTS CLOSURE OF INCISIONS REMOVAL OF BODY INVASIVE DEVICES WASHING AND DRYING OF THE BODY PACKING ALL ORIFICES TREATMENT OF DISTENTION EMBALMING REPORT RE-SETTING AND GLUING THE FEATURES PLASTIC GARMENTS CLEANING - MACHINE & PREP TABLE, INSTRUMENTS SHIP-OUTS CHECK FOR: dehydration of the tissues purge any type of leakage softening and discoloration of the tissues gas formation separation of the lips and eyelids odors cosmetic changes Cleaning under the fingernails Making sure the clothing is clean and pressed Rinsing the fluid bottles three times so they can be placed in the regular trash Doing the laundry

SKIN DONORS

Skin is usually taken from the back, chest, thighs, but on larger donors can be taken from the arms as well. In all cases, if skin has been taken from the back side of the body two embalmers will be needed to roll the body and administer necessary treatments.

EMBALMING 13 - 75 YEAR OLDS (ADOLESCENTS AND ADULTS)

Supplemental fluids Preinjection- has little to no preservative used before the arterial fluid to help prepare the body by clearing intravascular blood discoloration, removing blood in vascular systems, and adjusting the pH of the tissues only used in unautopsied bodies Coinjection- Enhances the arterial solution by controlling the preservative Used in waterless embalmings Solution Strength & Volume Each chemical company makes a different embalming fluid. If you only use Pierce/Royal Bond and go to work for a funeral home that only uses Dodge, don't try to use the Dodge in the same way as the Pierce/Royal Bond. Just ask someone- it's not a sign that you don't know what you are doing, it's a sign that you want to do a good job and you simply have experience with another embalming fluid manufacturer. Pressure & Rate of Flow Ideal are 10 to 15 minutes per gallon and 5 to 20 lbs. pressure (5 for injecting the face and up to 20 for the rest of the body).

EMBALMING AUTOPSIED INFANT

Up to 75 % of infants are autopsied. The 4 types of infant autopsies are: Complete Autopsy- includes cranial and trunk cavities Partial Autopsy- only 1 cavity is opened Cranial Thoracic Abdominal Spine Special or Local Autopsy- only one organ is removed Organ Donor Autopsy- can include removal of the eyes Always try to use the major vessels first, just like an adult, and: Use normal strength solution (the infant has up to 75% water ratio in the body) Use small arterial tubes Embalm the legs first so that the fluid strength can be adjusted if needed Massage is used to help distribute the fluid Supplemental Embalming includes: Hypodermic Injection Internal Compresses- cotton or sheets soaked with cavity fluid or autopsy gel and placed in the open cavities before incision closure Preservative gels- brush on autopsy gel in open cavities External compresses- the potential problem with these is the uneven distribution of the preservative. It can leave a blotchy look. Pressure should be applied evenly. Autopsy Viscera Treatment Same as adults Closure of cavities The infant calivarium can be much softer, use care when suturing the cranial autopsied infant.

AUTOPSY - FLUID STRENGTH & DYES

Usually a stronger than average arterial solution is used due the fact that most autopsied bodies undergo delayed embalming after being refrigerated for several days. Delays increase the possibility of distention during arterial injection and also increase the preservative demand of the tissues. The use of dyes in autopsied bodies is as effective and just as important as in unautopsied bodies.

DIABETES MELLITUS

Usually circulation is poor A strong solution is recommended Use a dye to tell where the fluid is present Use the restricted cervical injection Cavity embalming should immediately follow arterial injection Adequate cavity fluid should be used

VERTEBRAL DONOR

Vertebral refers to a spinal recovery and the length of the spine taken will vary greatly. Depending on how much has been taken, loss of rigidity of the remains is the primary concern along with leakage from the site. There are multiple ways that the spine may be harvested and the method used will determine how the embalming should proceed. Following recovery with autopsy or organ donation- use the vessels that been left exposed to complete the embalming while watching and being aware of the potential for leakage. Following recovery via an anterior incision- it is best to open the incision and determine which vessels are there and can be used before making addition incisions for vessels. Following recovery via a posterior incision- if done properly this method allows for the removal of the spine without disrupting the vascular system.

EMBALMING UN-AUTOPSIED INFANT

Vessel Selection Common Carotid is most commonly used because of its size. It is very shallow in infants. Femoral (external iliac) The external iliac is larger than the femoral and can be used. The accompanying vein can also be used. Axillary Aorta- I don't recommend this method. It is extremely difficult and I believe border on mutilation. I would only use this method if you can be taught by an experienced embalmer, who can be right with you every step of the way. The pictures in the textbook make this look easy- it's actually difficult. Ascending Aorta- I would never use this method in part because the incisions are so close to an autopsy. We are embalmers, not medical examiners/pathologists. Cavity Treatment Use an infant trocar. The amount of cavity fluid used depends on the size of the infant.

EMBALMING 4 -12 YEAR OLDS

Vessel selection. Use the: Common carotid and jugular Femoral artery and vein These arteries are usually in good condition as the leading cause of death is accident in this age group. Fluid Strength and Volume Use 18 to 25 index fluid Volume- use more than in the infant but less than an adult- depends on the weight of the child. Pressure and Rate of Flow The rate of flow should be less than that of an adult. Too much pressure can remove too much moisture and give a wrinkled appearance. Setting the features Arms are usually to the side Be aware of braces and buckteeth. It may be harder to close the mouth if these are present.

ARTERIOSCLEROSIS

When present use the common carotid artery.

RATE OF FLOW

is the speed at which the solution enters the body and is measured in ounces per minute. The rate of flow causes the most concern to the embalmer because it can cause uneven distribution throughout the body and distension of the tissues. When using a centrifugal pump injector it is recommended that the pressure be set with the rate of flow valve closed. Another name for the rate of flow valve is the stopcock. The pressure set with the rate of flow valve closed is called the potential pressure. When the rate of flow valve is opened and the machine is turned on it is called the actual pressure. The difference between the actual pressure and the potential pressure is the differential pressure. Each embalmer has their preferences based on theory regarding the correct rate of flow. Remember these points as you form your own biases: Bodies recently deceased can be injected faster than bodies that have been dead for a long period of time by using a low pressure. Different areas of the body accept fluid differently. For example, you would be more inclined to inject a leg with a greater rate of flow and inject the head and face with a lower rate of flow. As the body is embalmed resistance increases causing the rate of flow to be slowed down. The pressure needed to overcome the vascular resistances of the body to distribute the embalming solution to all body areas is the definition of ideal pressure. The rate of flow needed to achieve uniform distribution of the embalming solution without distension of the tissues is the definition of the ideal rate of flow. The rate of flow used to be determined by gravity devices used to embalm. Today the rate of flow is determined by: The size of the delivery hose Size of the arterial tube Resistance within the body To increase the rate of flow the pressure in increased. To decrease the rate of flow the pressure is decreased.

AUTOPSY ASPIRATOR - CAVITY EMBALMING

it is designed to be a non-clogging instrument so that the embalmer can keep it in the cavity during the embalming and doesn't have to watch it closely. It is about 8 in. long.

DIFFUSION

movement of the arterial solution intravascular to extravascular by way of the capillary walls.

DELIVERY

of the fluid from the machine through the arterial tube and into the artery.

ORGAN DONATION

refers to the procurement and transplantation of a body that fulfils one of those specific functions. Based on those definitions a cornea transplant is a tissue transplant.

TISSUE DONATION

refers to the procurement and transplantation of tissues that fall into one of these four basic tissue categories: 1. epithelium 2. connective tissue 3. muscle tissue 4. nerve tissue.

ARTERIAL EMBALMING

the injection of a suitable arterial solution, under pressure, into the blood vascular system to accomplish temporary preservation, sanitation, and restoration of the dead human body.

DISTRIBUTION

the movement of the fluid into the arterial system and into the capillaries.