3.1: Autopsies

aa partial autopsy may include:

-Cranial only -Thoracic only -Abdominal only

work practice controls

-be aware of sharp and cuttings instruments around you -cover broken bones before placing hands in the cavities -wash gloved hands or change gloves often during the procedure -avoid use of high water pressure -continuous aspiration of body cavity -clamp leaking arteries and veins to avoid loss of fluid -run water across the table continuously -peck external orifices -soak removed sternum and calvarium and preservative solutions in a closed container Watch for broken bones/rib cage Avoid high water pressure (but use continuous water flow) Don't flip ligature (when removing temporary sutures) Continuous aspiration Clamp leaking arteries

How to keep hair out of the way:

-comb out of way with water -use hair clamps -moisten hair with liquid soap and comb away

2 kinds of autopsies include:

-complete autopsy -partial autopsy *note that a corner autopsy will almost always be complete

complete includes:

-cranial cavity -eye enucleation -removal of neck organs -thoracic cavity -abdominal cavity -pelvic cavity -spinal cord -testes from scrotum -possible tissue samples

medical or hospital autopsy is performed when:

-doctors have not made a firm diagnosis -death from unexpected medical complications -as a result of an experimental decide procedure or therapy -death after dental or surgical procedure done for a diagnostic purpose and case is not under jurisdiction of ME or coroner -when death occurs suddenly but does not come under jurisdiction of ME or coroner -environmental or workplace hazard suspected -occurs during child birth -concerns of hereditary disease -concerns of spread of contagious disease -quality of care is questioned AND to verify a diagnosis and teaches diagnostic techniques in teaching hospitals

removal of spinal cord

-dorsal approach: body is turned over and vertebral column is opened -ventral approach: vertebral column is opened from within the cavities and cervical area -removal from foramen magnum OR -sample removal of spinal cord from ventral approach

needed for closing up:

-double curved suture needle -linen suture cord -minimum of five-twist linen suture cord used

eye enucleation or vitreous humors of the eye

-electrolytes can show dehydration -glucose levels can indicate diabetes -vitreous ethanol can indicate alcohol increase or decreasing when compared to blood

pressure and rates of flow in this case

-inject each section separately -higher pressure and faster rates of flow can be safely used because of this in arms and legs to establish good circulation -intermittent drainage and pulsation can be used to aid

what should be done to help embalm deeper tissues in these cases?

-massage heavily -use intermittent drainage

strength of fluid

-preparation will be delayed and the body will have been refrigerated -as a result a stronger than average solution should be used -delays increase possibility of distention

general prep:

-remove any stitches and expose cavities -spray cavities with disinfectant -disinfect and treat calvarium -support scalp flag so there is no visible crease during injection -inspect arteries -mix solution and inject lower extremities first -inject upper extremities

special considerations

-some families may as for limitations -ALL parts of the body are entitled to be received by the family including tissue samples -the funeral home should note what kind of an autopsy was performed and if not all organs were returned

arteries for upper extremities

-subclavian arteries are preferred due to distribution to neck, shoulders, arms and hand -axillary if needed but NOT ideal

supplemental hypodermic injection options may include:

-the trunk must be channeled -cut inner muscles such as intercostals and later paint with autopsy gel -must paint all inside surfaces with autopsy gel -line cavity with cotton or paper towels before placement or organ bag. Saturate material with cavity fluid or another preservative

neck organs

-thyroid gland -larynx -cervical portion of the esophagus and trachea -common carotid arteries POSSIBLY -removal of tongue

what vessels may need to be clamped when injecting the subclavians?

-vertebral artery -internal thoracic artery -inferior thyroid artery (when neck organs are removed)

final steps:

-wash and dry body -seal incisions with surface glue (some cover with cotton) -if air is trapped in cavity insert trocar just under the skin -may need to dress in plastic

characteristics of the diff autopsies:

1. Medical (Hospital) Autopsy: Verify or confirm diagnosis (e.g. CJD) Common at teaching hospitals 2. Medicolegal (Forensic) Autopsy Ascertain the cause and/or manner of death Violence, trauma, sudden deaths not attributable to disease 3. Partial autopsy Only one cavity is opened (cranial, thoracic, abdominal)

case in which an autopsy MUST be performed:

1. homicide 2. death in the workplace 3. pedestrian accident 4. motor vehicle accident 5. passengers involved in an accident 6. victims of intra and perioperative accidental deaths 7. epileptics 8. sudden infant death syndrome 9. infants or children with visible body injuries 10. inmate fatalities 11. trauma victim 12. sudden and unexplained death 13. anorexia nervosa 14. multiple victims of an unexplained event in an area 15. poisonings or overdose 16. any case where the pathologist sees it as unexplained and can only determine cause via an autopsy

Two types of autopsies?

1. medical (hospital) 2. medico-legal (forensic)

thoracic autopsy

Drainage from lower extremities and abdomen: inferior vena cava Inject head and arms same as normal post Lower extremities: Use thoracic aorta; OR... Inject femoral arteries (superiorly and inferiorly)

supplemental hypodermic injection

Hypovalve trocar on trunk walls, buttocks, breasts, shoulder & neck Distribution to abdominal walls during injection of iliac arteries Pack pelvic cavity (prevents rectal leakage) Powder cavity Fill out the neck region Hollowed-out area is very noticeable upon dressing

abdominal autopsy

Inject legs via external iliac arteries Thorax, upper extremities, & head: Abdominal aorta R. common carotid artery Clamp abdominal aorta RCI

Viscera

Internal organs enclosed within a body cavity

3 cranial autopsy methods

Method 1: RCI Clamp vertebral artery Method 2: Inject RCC only Clamp L. internal carotid and vertebral arteries Method 3: Femoral injection Clamp all vessels in brain (R & L internal carotids and R & L vertebrals)

closure of the main body cavity

Position sternum first (covered on both sides w/gel or powder) Bring three flaps together in middle - tie w/one suture Suture from this point towards one shoulder Pull on ligature NOT needle Start abdominal suture at pubic symphysis When you hit the middle of the Y, continue up towards other shoulder Incision sealing powder is important in shoulder areas: common leakage spot

Autopsy

Postmortem examination of the organs and tissues of a body to determine cause of death or pathological condition

pre-embalming analysis

Preparation is usually delayed Between death and autopsy or between autopsy and release of body. Normally requires a stronger-than-average arterial solution Pre-injection would NOT be recommended! Extended refrigeration can cause DEHYDRATION Different type of solution? Delays INCREASE the possibility of DISTENSION

injecting the head

R & L common carotid arteries Inject left side first to avoid over-embalming the right side L & R internal carotid arteries must be clamped (in the cranial cavity) Circle of Willis: arterial circle at the base of the brain which supplies blood to the brain

injecting the lower extremities

R & L common iliac arteries Look for leaking from internal iliacs (in pelvic cavity) Drainage will flow into main body cavity via common iliac veins (or IVC) Hemostat (or digital pressure) for intermittent drainage Volume/strength depend on pathological conditions

injecting the upper extremities

R & L subclavian arteries Distribution to shoulders, back of neck, upper back Not achieved when axillary artery is used IMPORTANT: Must clamp the vertebral artery (in cranial vault) when injecting the subclavians!

Eye enucleation

Removal of the eye for tissue transplantation, research, and education

pre-embalming prep

Remove viscera bag and sternum DO NOT handle the viscera bag assertively Cavity fluid (or SynGel HV) can be poured into the viscera bag Coat the sternum in Syn-Gel HV or Basic Dryene Wrap sternum in cotton and soak with Phenol Place the bag in a stainless steel bucket

suggested order of preparation:

Set features Remove viscera Ligate vessels Mix solution Begin injection: Legs Arms Head (which side first-LEFT BITCH) Supplemental treatments Dry cavities and add compound or gel Return viscera bag

What are the refrigeration concerns?

Subcutaneous tissue may become firm due to low temperatures False sign of distribution Can lead to swelling if RoF is too high Bring about hemolysis of blood trapped in superficial tissues Can be mistaken for dye/distribution BENEFIT: Can keep blood in a liquid state

methods of calvarium attachment include:

Suture through temporal muscle Calvarium clamps Superglue Plaster of Paris Needle injector wires Drill holes & wire Bald head - glue

What side of the head should injection begin?

THE LEFT SIDE BITCHHH

Circle of Willis

The circular arterial structure at the base of the brain from which all the principal arteries that supply brain branch

Anastomosis

The connection of normally separate parts, for example, a connection of two blood vessels

Bifurcation

To divide into two parts or branches

autopsy aspirator

Used to aspirate (suction) blood and arterial fluid from the cavities of autopsied bodies. It has many openings to avoid clogging

What are the embalming considerations?

Vary the pressure and rate of flow depending upon which area is being injected. NO drainage devices are necessary. Drainage from lower extremities? Drainage from upper extremities? Drainage from head? Can still use intermittent drainage

treatment of viscera

Viscera have been soaking in cavity fluid in the bag Some embalmers pour cavity fluid AFTER bag has been placed in the cavity Some embalmers remove the viscera, coat in powder, and place them each into the cavity Cotton over severed ribs to prevent bag from tearing Aspiration hose in bag with ligature around hose Remove air and tie bag up high so there is room for viscera to move

When can you STOP injecting the arm?

amount needed will always vary. Want to see clear nail beds and color in the knuckles, fingers and palms

left subclavian branches off of the:

aorta

suturing the skull:

begin sutures on right side of the head and end them on the left side -use a double curved needle, tie first suture behind right ear -do not use knots they will pull through -two sutures the can be used include: inversion (worm) stitch or a baseball stitch-NO THREAD SHOULD BE SEEN

right subclavian is a branch of the:

brachiocephalic artery

Why should the left be injected first?

come fluid will reached the right side as a result of flowing through anastomosis. If any problems occur the occur first on the left side (the lest viewed side)

when an embalmer is working alone:

do one item at a time (only inject legs and only pay attention to the legs before moving on, for example) DO NOT try and feature set or raise other vessels at the same time

use of fluid dyes

dye is the BEST sign of distribution in this case. Refrigeration, rigor and delay can all lead to signs of false arterial distribution

What vessel should be used when injected the head if the carotid has been destroyed by the pathologist?

external carotid

ideal artery for legs?

external iliac if not intact enough may have to raise the femoral

drainage in the autopsy case

it is NOT NECESSARY to insert a drainage device -drainage is taken directly from severed and cut veins

death within 24 hours upon admission to a hospital is not considered reportable unless:

it meets one of the criteria

What happens when only one organ has ben removed by the pathologist did not litigate vessles?

loss of arterial solution so the embalmer should litigate the vessels

words for an autopsy

necropsy or postmortem

partial autopsy

only one cavity is opened (cranial, thoracic, abdominal, or spine) and only one or so organs may be removed

What areas need special attention?

pack pelvic cavity and replace missing organs in neck with cotton or another alternative for normal appearance -saturate with preservative fluid

cranial cavity

removal of inner ear, brain, pituitary gland

treatment of viscera includes:

remove viscera and put in bucket. if any liquid from viscera is present, drain it. open viscera with scissors or scalpel. pour a minimum of 2 bottles of cavity fluid over viscera, mix it all thoroughly, then cover the bucket. aspirate all cavities and wash the remains with warm soapy water

where can vessels be clamped to stop drainage in the arms?

subclavian or axillary veins

What vessel must be clamped when injected the left common carotid?

the left internal carotid artery

What vessel should be clamped when injected the right common carotid?

the right internal carotid

lock down technique

tying off after every 5 sutures in the Y incision

prep of the body

unwrap, disinfect bag, gentle roll body and roll body bag to contain fluid contents put in biohazard RIGHT AWAY

closing of the head

Can be sutured or stapled Notch in calvarium Make notches for calvarium clamps Reflect scalp forward, add Webril and soak in Dryene to cauterize tissue around the skull Prior to injection Use incision sealer if needed (hard to wash out of hair) If you have dried tissue effectively, skin staples will work well

cases reported to a medical examiner or coroner:

1) all sudden deaths 2) all deaths occurring in suspicious circumstances 3) all deaths occurring as a result of violence or trauma 4) any fetal death, stillbirth or death of a baby within 24 hours of birth where mother has not been under care of a physician 4) all therapeutic and criminal abortions beyond 16 weeks gestation 5) all operative and perioptive deaths not explainable on basis of prior disease 6) any death where body is unidentified or unclaimed 7) any death with uncertainty if it should be reported to to coroner or ME

reasons for medico-legal autopsy ordered by a coroner or ME because:

1) determination of a 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 info for legal authorities 6) separate deaths due to disease from deaths due to external causes

suggested order of the autopsied body

1. primary disinfection of the body 2. position of the body using block and bridges as needed 3. open the cavities and remove all viscera 4. decide on treatment method for viscera 5. locate and ligate the vessels needed for sectional embalming: - r & l external iliac arteries - r & l axillary or subclavian arteries - r & l common carotid arteries 6. prepare arterial solution according to proper analysis:- cause of death- size and weight of body- moisture content, or lack of moisture- time interval b/t death and preparation 7. begin sectional embalming:- legs- arms- head; left side first 8. supplemental hypodermic injections:- trunk and ribs- shoulders and neck- buttocks and perineal area 9. drain all liquids from body cavities 10. treat all internal surfaces with hardening compound or gel 11. return visceral, in sections or in bag 12. suture thoracic and abdominal cavities 13. dry cranial and treat with powder or gel 14. suture the scalp 15. perform terminal disinfection 16. glue thoracic and abdominal incisions 17. cress in coveralls or unionalls if needed PREPARE THE EMBALMING REPORT

How long should the topical disinfect remain on the body before continuing during prep?

10 minutes

head closure in the autopsy case

Baseball or worm (Inversion) suture Super adhesive (Aron Alpha) Putty along the cut line of the forehead Smooth out any contour Start on the right and work towards the left Excessive shampoo/hair clamps to keep hair in place