Embalming 2 Chapter 17: Preparation of Autopsied

*WORK PRACTICE CONTROLS*

*(1) Be aware where cutting and sharp instruments are laid during preparations.* *(2) Cover broken or cut bones (ex. ribs) prior to placement of embalmer's hands into a body cavity.* *(3) Wash gloved hands or change gloves often during embalming procedure* *(4) Avoid use of high water pressure when water is used to flush blood and fluids from the embalming table* *(5) Practice continuous aspiration of the cavities during arterial injection to remove drainage and excess arterial fluid.* *(6) Clamp leaking arteries and small veins to avoid excessive embalming solution loss and improve solution distribution during arterial injection.* *(7) Run table water continuously to dilute and carry away any blood or chemicals on the table surface.* *(8) Pack external orifices: rectum, esophagus, trachea, ears, and vagina.* *(9) During embalming, the calvarium and the removed portions of the sternum can be soaked in a preservative solution in a closed container or sealed plastic bag.*

*Ways in which hair can be kept out of the suture line*

*(1) Comb the hair out of the way with water.* *(2) Use hair clamps to "clamp" the hair away from the sutures.* *(3) Moisten hair with liquid soap and comb the hair away from the incision line.*

*Complete Autopsy Includes*

*(1) Cranial and Cavity and its contents:* a. Possibly removal of inner ear b. Brain c. Removal of the pituitary gland *(2) Eye enucleation or vitreous humors of the eye:* *(3) Removal of the neck organs:* a. Thyroid gland b. Larynx c. cervical portion of the esophagus and the trachea. d. Possibly the removal of the common carotid arteries. e. Removal of tongue *(4) Thoracic cavity and its contents* *(5) Abdominal cavity and its contents* *(6) Pelvic cavity contents* *(7) Removal of spinal cord:* a. *DORSAL APPROACH:* body is turned over and vertebral column is opened. b. *VENTRAL APPROACH:* vertebral column is opened within the body cavities and cervical area. c. Removal from the foramen magnum d. *SAMPLE REMOVAL* of the spinal cord. *(8) Removal of testes from the scrotum* *(9) Tissue samples may be taken from any region of the body.*

*Reasons for a Medico-legal Autopsy ordered by a coroner or medical examiner include:*

*(1) Determination of the cause of death* *(2) Determination of the manner of death* *(3) Establishment of the time of death* *(4) Recovering, identifying, and preserving evidence.* *(5) Provide factual objective information for legal authorities.* *(6) Separate deaths due to disease from deaths due to external causes.*

*Abdominal Autopsy Method 1*

*Method 1* -Locate abdominal aorta to inject thorax, upper extremities, and the head. -The aorta can be located at the level of the vertebral column in the central posterior position of the diaphragm. -Tie or clamp an arterial tube in the aorta. -Upward inject should embalm the thorax and its contents, arms, and the head

*Thoracic Autopsy Method 1*

*Method 1* -Locate the terminal portion of the thoracic aorta on the vertebral column at the central posterior position of the diaphragm. -Insert a large arterial tube into the aorta -Clamp the tube in place with an arterial hemostat or tie tube in place if possible. -Inject downward through the arterial tube *This embalms the abdominal walls, abdominal contents, and lower extremities*

*Cranial Autopsy Method 1**

*Method 1* -Raise the right and left common carotid arteries. -Insert tubes in both, directed upward toward the head. -Insert 1 tube directed downward toward the trunk in the right common carotid. -Tie off (ligate) the lower portion of the left common carotid. -Use right internal jugular vein for drainage. -Inject downward first to embalm the extremities and the trunk. -Clamp off leakage in the cranium from the right and the left vertebral arteries. -Inject the left sides of the head, clamping off the left and the right internal carotid arteries.

*Cranial Autopsy Method 2*

*Method 2* -Raise right common carotid artery and the right internal jugular vein. -Insert 2 tubes directed upward toward the head and one tube directed downward toward the trunk. -Inject downward, clamping off the right and the left vertebral arteries and the left internal carotid artery. -Inject up the right side of the head. -Clamp off the right internal carotid artery in the base of the skull

*Abdominal Autopsy Method 2*

*Method 2* -Raise the right common carotid artery -Insert tube upward for the right side of the head. -Insert a tube downward -Inject downward toward the trunk; arms, thorax, and left side of the head. -Clamp or tie aorta when leaking -Inject right side of the head (RCI) -Check abdominal walls, buttocks, and back for distribtion

*Thoracic Autopsy Method 2*

*Method 2* -Raise the right femoral artery and insert tube directed upward toward the abdomen. -Also insert a tube downward to inject right leg. -Inject right leg first. -Next embalm upward, this embalms the left leg, the abdominal contents, and the trunk. -Ligate by tying or clamping the thoracic aorta when fluid is observed flowing from this artery into the thoracic cavity. -Check for preservation of the thoracic walls and back and the shoulders. -Paint thoracic cavity with autopsy gel and filled with sheeting or an appropriate absorbent material. -Breastplate can be put back and use baseball suture. -Aspirate the abdominal cavity and inject cavity fluid over the abdominal viscera

*Cranial Autopsy Method 3*

*Method 3* -Raise the right femoral artery and vein. -Insert into the artery 1 tube directed upward and one tube directed toward the foot. -Inject the right leg. -Inject upward toward the trunk and the head. -Clamp off right and the internal carotid arteries and the right and the left vertebral arteries. -After arterial injection, dry the cranial cavity, paint it with autopsy gel, and fill it with cotton. -Attach the calvarium and suture the scalp back into position using the inversion or baseball suture. -Spread plenty of incision seal powder or mortuary putty within the incision as the suturing progresses. -Begin suturing on the right side of the head and end on the left.

*Cervical Vertebrae*

*Occur due to broken neck from automobile wreck or falls* -Roll the body on its side, or completely over prior to arterial injection and remove the sutures. -Pack the area with a phenol cautery chemical. -Hold edges together with bridge sutures or several strips of duct tape. -After embalming, roll the body on its side or completely over. -Remove cautery packing, dry the deep tissues, fill the incision with seal powder or mortuary putty and tightly suture closed using a baseball stitch. -Coat sutures with incision sealer

*USED TO EMBALM DISTAL ARMS AND HANDS*

-Axillary arteries

*USED TO EMBALM HEAD AND FACE*

-Common carotid arteries

*Death from Drug Overdose*

-Generally a square of tissue is cut out, usually in the bend of the elbow. **Cannot be closed by suturing*** -Cover open areas with cotton saturated with phenol chemical prior to embalming. -After arterial injection, remove cotton, dry with a hair dryer, and paint the area with glue. -Apply fresh cotton and wrap the area. -Plastic sleeves may be needed for leaking. -Saran wrap the cotton.

*Partial Autopsy*

-Generally only 1 body cavity (cranial, thoracic, or abdominopelvic cavity) is opened to examine one specific item.

*Death from Pulmonary Embolism*

-Incisions are often made along the medial and the posterior areas of the lower legs. -These incisions can be filled with cotton packs dipped in a phenol cautery solution or cavity fluid while the rest of the body is embalmed. -After the other incisions are closed, cotton packs can be removed and the incisions can be packed with dry, absorbent cotton. -Baseball suture. -Stitching coated with surface glue. -Plastic stockings

*the incision on the back of a spinal autopsy can present this potential problem*

-Leakage

*Tissues taken from the knee area*

-Open prior to injection. -Should be dried with cotton and packed with cautery agent on cotton swabs. -After injection, dry out the area, fill with incision seal powder, and suture tightly using a baseball stitch. -Plastics may be needed

*Cranial Cavity*

-Phenol cautery chemical can be placed on cotton compress and laid along the autopsy incision where the scalp has been opened. -Arterial solution or blood that has accumulated in the posterior portion of the cranial cavity should be removed by aspirating or sponging. -Walls of the cavity can be painted with autopsy gel or preservative gel. -Absorbent material should be placed in the cavity to absorb the liquids. *Long Wood Dowel*-into the foramen magnum, this holds the head steady if the vertebral column has been opened for examination. -Calvarium can be removed and placed in plastic bag with phenol or cavity fluid. -Calvarium should be replaced

*the body is placed in this position for dorsal removal?*

-Prone

*Hospital Autopsies are performed when*

-When doctors have not made a firm diagnosis -When death follows unexpected medical complications. -When death follows the use of an experimental drug or device, a new procedure, or unusual therapy. -When death follows a dental or surgical procedure done for diagnostic purposes and the case does not come under the jurisdiction of medical examiner or coroner. -When death occurs suddenly, unexpectedly, or in mysterious circumstances from apparently natural causes and the case does not come under the jurisdiction of medical examiner or coroner. -When environmental or workplace hazards are suspected. -When death occurs during or after childbirth -When there are concerns about a hereditary disease that might affect other members of the family. -When there are concerns about the possible spread of contagious disease. -When the cause of death could affect insurance settlements (ex. policies that cover cancer or that grant double indemnity for accidental death). -When the death occurs in a hospital and the patient comes from a nursing home and the quality of care is questioned. -To confirm diagnosis -Autopsies serves as a tool for teaching hospitals to explain a diagnostic technique or disease process

*SECURING THE CALVARIUM*

-calvarium clamp (most common) -needle injector wires -adhesives -wiring between drilled holes -suturing through the temporals muscle

*prepare arterial solution according to proper analysis*

-condition of the body -size and weight -moisture content -time between death and treatment

*USED TO EMBALM LOWER EXTREMITIES & DISTAL PARTS OF THE LEGS*

-external iliac arteries

*contract autopsy may be performed when...*

-family or POA request

*USED TO EMBALM gluteal, pelvic, and perineal areas*

-internal iliac arteries

*this side of the head is done first in sectional embalming*

-left

*cranial treatment*

-open cranial incision and remove the calvarium -ligate/clamp leaking vessels in the interior of cranium -inject both R&L internal carotid and R&L subclavian arteries

*General recommendations of Autopsy*

-preparation of autopsied bodies is usually delayed -use a stronger than usual or average arterial solution -use plenty of active dye -embalm the head slowly

*removal of the spine from an incision made on the back*

-spinal autopsy dorsal removal

*removal of the spine from normal autopsy incision (front)*

-spinal autopsy ventral removal

*in a proper autopsy there are notches in area of this bone*

-temporal

*why would it be necessary to pack the neck area*

-to conform to natural contours

*what are the notches for in the area of the temporal bone?*

-to keep the calvarium from moving

*when would a cavity pack be needed in the mouth?*

-tongue is missing

*embalming case report should note this*

-treatment and disposition of the viscera -was viscera present -was viscera stripped or sectioned -did you return viscera to the body -was viscera treated with powder or fluid -was viscera placed in separate bag outside body

*supplemental hypodermic injections*

-trunk and ribs -shoulders and neck -buttocks and perineum area

*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.If necessary place appropriate plastic protective garments on the body: embalming powders should be placed inside the garment. 16. Prepare the embalming report.

*Protocol for Treatment of Autopsied Body with Restorative*

1.) Disinfect and position body. 2.)Asses the damage to all body areas 3.)Begin with injection of the legs; then inject the arms. 4.)Prepare the head and face: a.)Open the cranial cavity and check for fractures b.)Shave the body c.)Inspect for fractures of the mandible with digital pressure. d.)Close the mouth e.)Close the eyes with cotton support f.) Attempt to realign fractured bones G.)Allign lacerated tissues H.)Prepare a very strong arterial solution 25 index and above. Dye should be added to arterial solution. I.) Inject left side of the face first. Pulse fluid into the head and observe the dye to check fluid distribution

*TYPES OF AUTOPSIES*

1.) Medical (Hospital) 2.) Medico-legal (forensic) 3.) Partial/complete 4.) Contract

*Cranial Cavity Methods of Attachment*

1.) Suture through temporalis muscles and up across the calvarium. Suture through the cut portion of the temporalis muscle still attached to the temporal bone and through the portion of the muscle still attached to the calvarium. 2.) Seperately suture the cut temporalis muscles on either side of the head. 3.) Use calvarium "clamps" 4.)Drill opposing holes in the calvarium and the temporal bone and wire the calvarium into position 5.)Use superglue to help hold the calvarium into position. 6.)Use plaster of paris. Used if skull is fractured. The base of the skull would be aligned and plastered into position (prior to arterial injection). The cranial cavity can be filled with cotton and this can be covered with plaster, and the pieces can be placed together. 7.) Use needle injector wires. Use 4 wires on each side: 2 attached to the calvarium and 2 attached to the temporal bone. Then crisscross wires.

*Factors Determined During Embalming Analysis*

1.) Vessels for injection and drainage 2.) Method of mouth closure 3.)Strength of the embalming solution 4.)Volume of the embalming solution 5.) Injection pressure 6.) Injection rate of flow

*vessels needed for sectional embalming*

R&L external iliac arteries R&L axillary or subclavian arteries R&L common carotid arteries

*Supplemental Hypodermic Injection*

Supplemental Hypodermic Treatments - 1. Buttocks 2. Breast 3. Shoulder 4. Neck Plus any untreated areas Treat with hypovalve trocar

*general guidelines for autopsy*

any child with evidence of injury without explanation suspected drug overdose motor vehicle accidents death in workplace pedestrian accidents suspected poisoning unexplained deaths prison fatalities homicide trauma SIDS anorexia nervosa eplieptics homicide

*these organs may be removed in an exploratory or partial autopsy*

brain heart lungs kidneys stomach

*After arterial injection of the head be sure to do this to the interior of the cranium*

clean and dry cover base of skull with quick drying sealer

*medico-legal autopsy may be performed when...*

death of a mother during abortion fetal death within 24 hours of birth spontaneous abortions miscarriages operative and peri-operative death unidentified/unclaimed body violent/traumatic death suspicious death sudden death uncertainty

*problems the embalmer faces if the body is in the prone position*

disfigurement discoloration distention

*when viscera is not present these can be used to fill the cavity*

excelsior cedar chips clean sheets clean sawdust padding/upholstery

*AFTER THE CALVARIUM IS SECURED*

full bone incision with mortuary putty of mastic compound use powdered sealer on the reflected scalp and return scape to its normal position

*sectional embalming is done in this order*

legs arms head

*ORIFICES PACKED or LIGATED*

pack vagina pack nose pack mouth pack trachea ligate rectum ligate esophagus

*suggested order for preparation of autopsy*

primary disinfection position body open cavities remove viscera decide on treatment for viscera locate and ligate the vessels needed for sectional embalming

*USED TO EMBALM SHOULDER AND UPPER EXTREMITIES*

subclavian arteries / distal

*USED TO EMBALM THE NECK*

subclavian arteries / proximal

*recommended methods for closing a cranial incision*

whip static h worm suture intradermal suture surgical adhesives baseball stitch