Chapter 9 Embalming Vessel Sites and Selections

One of the major objectives of making a preembalming analysis of the body is

the selection of vessel to employ for injection and drainage

Considerations and Precautions when selecting an Artery for Embalming

Accessibility

Superficial or deep

Surrounding structures

Proximity of aorta

Size (diametric)

Effect on posing the body

Location regarding the exposed areas

Practicability of draining corresponding veins

One-Point Injection

An artery and vein at one location are used for injection and drainage (e.g. injection from the right common carotid artery and drainage from the right internal jugular vein, or injection from the right femoral artery and drainage from the right femoral vein)

Center of Circulation for the Embalming Process

Arch of the Aorta

Branches off the arch of the aorta

Brachiocephalic

Left Common Carotid

Left Subclavian

Collateral Circulation to Brain

Anterior

Common Carotid Artery (L&R)

Internal Carotid Artery (L&R)

Circle of Willis

Posterior

Subclavian Artery (L&R)

Vetebral Artery (L&R)

Basilar Artery (unpaired artery)

Circle of Willis

Arteries of Head and Neck

Common Carotid Artery

Place of Incision

Half-Moon (Semi-Lunar)

from the center of one clavicle by a curve to the center of the other clavicle.

Parallel

Along the posterior border of the inferior one-third of the sternocleidomastoid muscle

Supraclavicular

Along the superior border of the medial one third of the clavicle.

Positive Considerations for Common Carotid

Direct Distribution to Face

Close to Center of Venous Drainage

Close to Center of Circulation

Face possibly can be embalmed with a mild solution, while remaining portion of body can be injected with a higher index solution.

Has no branches except its terminal branches

Precautions

Incision may be visible after dressing

Tubes may leave mark on face

Face may be over-injected

Facial Artery (place of incision)

Along the inferior border of the mandible just anterior to the angle of the mandible

Arteries of the Upper Extremity

Axillary Artery

Brachial Artery

Radial Artery

Ulnar Artery

Axillary Artery: Place of Incision

Along the anterior margin of the hairline of the axilla.

Axillary Artery:Positive Considerations

Close to face

Close to center of circulation

Close to center of venous drainage

Vessels are relatively superficial

Axillary Artery:Precautions

Danger of over-injecting the face, particularly if there is any obstruction present in the other trunk arteries of the body.

Numerous Branches

The anomalies of both artery and vein are common.

If the arm is not treated properly, it does not appear natural when the body is placed in the casket.

Brachial Artery

Place of Incision

Along the linear guide

Positive Considerations

Same as those as the axillary artery

Radial Artery

Place of Incision

Just lateral to the tendon of the flexor carpi radialis muscle

The linear guide at the wrist

Ulnar Artery

Place of incision

Between the tendons of the flexor carpi ulnaris and flexor digitorum superficialis muscle

Linear guide at the wrist

Arteries of the Trunk (Autopsied Bodies Only)

Brachiocephalic Artery

Subclavian Artery

Aorta Artery

Common Iliac Artery

External Iliac Artery

Internal Iliac Artery

External Iliac Artery

Anatomical Guide

Along the medial border of the psoas major muscle

Arteries of the Lower Extermity

Femoral Artery

Popliteal Artery

Anterior Tibial Artery

Posterior Tibial Artery

Dorsalis Pedis Artery

Femoral Artery

Positive Considerations for Femoral Artery

Large in Size

Lower portion of the body can be embalmed without concern of distention of face

Vessels are deep-seated in obese cases

Drainage is sometimes difficult to establish and maintain

Even fluid distribution to both sides of the face.

Arms can be placed in natural position and allowed to remain there.

Precautions for utilizing the femoral artery

Vessels are deep-seated in obese cases

Drainage is sometimes difficult to establish and maintain.

Popliteal Artery

Place of Incision

Longitudinal incision on the postero-medial aspect of the thigh just superior to the popliteal space.

Anterior Tibial Artery

Place of Incision

Along the lateral margin of the inferior third of the crest of the tibia.

Posterior Tibial Artery

Place of Incision

Midway between the medial malleolus and calcaneous tendon.

Factors Governing Selection of Artery to be used in Embalming

Age (infant-adult)

Sex (carotid in female)

Weight (fat distribution)

Disfigurations (arthritis)

Mutilation (accident, surgery)

Disease (anasarca)

Cause of Death (cancer, etc.)

Local obstruction (congestion)

Religion (nuns)

Proper Technique for Raising Vessels

Select Instruments - prepare ligature

Make proper incision

Find vessels by us of anatomical guide and relative position of vein

Clean off vessels by blunt dissection and ligate loosely

Make incision in vessels

Types of Incisions (p. 189 old 176 new)

Transverse Incision

Longitudinal Incision

Triangular Incision

Variations

Vessel Raising (cont'd.)

Insert instruments

Secure instruments by ligation or arterial forceps

Close incisions following injection

Types of Sutures to close incisions

Baseball (p. 281 old 274 new)

Draw or Worm (p. 283 old 275 new)

Single Intradermal (p. 282 old 274 new)

Double Intradermal (p. 282 old 275 new)

Lock (p. 283 old 275 new)

Whip (roll) (p.283 old 275 new)

Purse String (p. 284 old 277 new)

DURING ARTERIAL EMBALMING FOUR PROCESSES TAKE PLACE AT SAME TIME

INJECTION OF THE ARTERIAL SOLUTION

DISTRIBUTION OF THE EMBALMING SOLUTION

DIFFUSION OF THE EMBALMING SOLUTION

DRAINAGE OF THE CONTENTS OF VEINOUS SYSTEM

INJECTION TECHNIQUES

PRIMARY INJECTION SITE

SECONDARY INJECTION SITES

ONE POINT INJECTION

COMMON CAROTID AND FEMORAL ARTERY

COMMON CAROTID ARTERY AND INTERNAL JUGULAR VEIN

ONE POINT INJECTION

THE GREATEST DISADVANTAGE OF THE ONE POINT METHOD OF INJECTION AND DRAINAGE IS THE SHORT CIRCUITING OF ARTERIAL FLUID

FLUIDS FOLLOW THE PATH OF LEAST RESISTANCE

MASSAGE, MANIPULATION, AND RESTRICTION OF DRAINAGE ALL HELP

ONE POINT INJECTION (CONT'D)

COAGULA IN THE ARTERIAL SYSTEM CAN EASILY BE PUSHED INTO MINUTE ARTERIAL TRIBUTARIES

SHORT CIRCUITING IS CAUSED NOT SO MUCH BY THE USE OF ONE-POINT INJECTION AS BY THE UNRESTRICTED DRAINAGE

SPLIT INJECTION

REDUCES SHORT CIRCUITING OF THE SOLUTION

USUALLY RIGHT INTERNAL JUGULAR VEIN (DRAINAGE) AND RIGHT FEMORAL ARTERY (INJECTION)

SPLIT INJECTION (CONT'D)

REQUIRES TWO INCISIONS, REQUIRES MORE TIME FOR SUTURING AND LIGATION OF VESSELS

MULTISITE (MULTIPOINT) INJECTION

CAN BE USED AS A PRIMARY INJECTION TECHNIQUE

SIX POINT INJECTION INVOLVES THREE MAJOR PAIRS OF VESSELS: COMMON CAROTID, FEMORAL, AXILLARY

SITUATIONS FOR MULTIPOINT INJECTION

REMAINS DOESN'T RECEIVE ARTERIAL SOLUTION

REMAINS DEAD FOR EXTENDED PERIODS

REMAINS WITH EVIDENCE OF DECOMPOSITION

DEATH DUE TO AORTIC ANEURYSM

DEATH DUE TO CONTAGIOUS DISEASES

SITUATIONS FOR MULTIPOINT INJECTION Con't

REMAINS WITH GENERALIZED EDEMA

REMAINS WITH TISSUE GAS

AUTOPSIED REMAINS

ANY COMBINATION OF TWO OR MORE ARTERIES FOR INJECTION CONSTITUTES A MULTISITE INJECTION

RESTRICTED CERVICAL INJECTION

INVOLVES THE USE OF BOTH COMMON CAROTID ARTERIES

BECOMING STANDARD PRACTICE FOR MANY EMBALMERS

RESTRICTED CERVICAL CASES

REMAINS WITH FACIAL TRAUMA

WHEN FACIAL DISTENTION IS ANTICIPATED

WHEN EYE ENEUCLEATION HAS BEEN PERFORMED

GENERALIZED EDEMA

DIFFICULT TO FIRM CASES

RESTRICTED CERVICAL CASES (CONT'D

DISTRIBUTION PROBLEMS CASES

HIGH FORMALDEHYDE DEMAND CASES

WHEN PURGE IS EXPECTED

Methods of Injection

Motorized force pump (centrifugal)

Types:

Pulsating

Non-pulsating

Methods con't

Considerations

Reliability

Pressure range

Volume

Ease of repair

Precautions

Servicing requirements and availability

Ease of use

Other methods of injection

Other methods of injection:

Gravity:

Use of gravity pressure - .43 lbs of pressure per foot of elevation above body.

Hand pump

Bulb syringe

Air pressure

Pressure

Potential pressure:

Actual pressure

Differential pressure

Setting pressures

Optimum pressure needed

Rate of flow

Factors that affect pressure

Intravascular influences

Condition of vessels

Vascular congestion

Extravascular influences

Weight of viscera

Gas in viscera

Tumors

Fluids in abdominal cavity (ascites) and extremities (edema)

Contact pressure

Cause of death

Post-mortem interval

Rigor mortis

Decomposition

discolorations

In the unautopsied body, the arteries most frequently used for embalming are

the common carotid, femoral and the axillary arteries

Once injection of the body is begun, the embalmer needs to continually ask two questions:

1. What areas of the body are receiving arterial solution?

2. Has an areas received sufficient arterial solution?

Four step method used during the embalming analysis before, during , and after arterial injection.

observation

evaluation

implementation

observe results

Selection of an injection site and vascular injection procedure involves two criteria

1. factors concerning the vessels

2. general body conditions

Situations in which it may be necessary to locate severed or cut portions of arteries to inject arterial solution include

1. bodies where extensive autopsies have been preformed

2. bodies where partial autopsies have been performed.

3. bodies from which one or more organs and or tissues for transplantation been removed

4. bodies with traumatic injuries

It is essential that the embalmer to able to distinguish between these structures.

Nerves - have a silvery appearance and when examined with the naked eye, shows striations along their surface, when cut ends looks like frays of rope

Veins - thinner than arteries. They contain valves which arteries do not. When cut, they collapse, creating a

funnel effect.

Arteries are very thick walls as compared with healthy veins. Arteries are creamy white in appearance and often, small vessels called the vas vasorum can be seen over the artery surface. The common carotid arteries are quite elastic. The femoral arteries are more muscular and not as elastic as the carotids.

The selection of an artery or arteries for embalming is based on conditions of the individual artery and condition of the body

1. How superficial or deep is the artery?

2. What structures surround the artery?

2. How close to the aorta is the artery

4. What is the diametric size of the artery?

5. Can the body be positioned properly if this artery is used?

6. Will incisions for the artery be on an exposed body area?

7. Can drainage be taken from the vein which accompanies the artery?

8. If arterial clotting is present, in what direction will these clots be moved during injection?

9. How much arteriosclerosis is present the artery at the injection site?

Other factors governing the selection of artery or arteries for injection

1. Age of the deceased

2.Sex of the individual with respect to the type of clothing which will be worn

3. Weight

4. Fat distribution

5. Dis figuration present

6. Disease present

7. Edema, localized or generalized

8. Location of obstruction or congestion, possibly creating discoloration or lack of preservative solution flow to a body region

9. Trauma presents from mutilation, accident, or surgery

10. Vascular interruption from organ and / or tissue donation

11. Medicolegal requirements regard to autopsies, preparation for medical school,preparation international shipping, preparation under military contract, requirement of coroner or medical examiner

12. cause of death

13. manner of death

Two non-variable guidelines must be considered in selection

1. Prepare each body with the asummpton that the body is dead from an infectious or contagious disease

2. Prepare each body with the assumption that final disposition and viewing will be delayed

Second group of factors include body condition

Age of body

weight of body

drainage is also a factor to consider with obese bodies

In obese bodies large quantities of arterial solution are needed to adequately preserve the body.

with very thin bodies care should be taken to minimize any destruction of the sternocleidomastoid muscle of the neck.

Diseased Conditions

Interruption of the vascular system

Clotting

Facial tissue distension

Facial Discoloration

Volume and strength of arterial solution

Medicolegal requirements

When the embalmer feels that clots are present in the arterial system, particularly in the aorta, the femoral artery should

not be used as the starting point. The best choice is the common carotid artery to begin

When the embalmer suspects that the blood vascular system is heavily clotted or that distribution of arterial solution will be difficult, the best vessel to be begin with is

the common carotid artery and drainage should be taken from the internal right jugular vein.. Restricted cervical can be an even better method controlling solution distribution.

The possibility of distension of the facial tissues during injection exists in

1. bodies dead for long periods of time

2. bodies with facial trauma

3. bodies that have been frozen or refrigeration for extended period of time

In an unautopsied body stronger solution may be necessary if

1.There is delay between the death and the embalming

2. the body shows evidence of decomposition

3.death was due to uremic poisoning or burns

4.Skeletal edema is present

Three methods of embalming can be used to treat body areas that have not received enough arterial solution

1. arterial embalming

2. hypodermic embalming

3. surface embalming

Multipoint injection of the head or limbs could include injection of one or more of the following arteries

head -right and left common carotid

Arm- left or right axillary, brachial, radial or ulnar arteries

Leg- the left or right external iliac, femoral, popiliteal, anterior tibial, or posterior tibial artery.

The embalmer raises the right femoral artery to inject the leg. Drainage can be taken from

1. the right internal jugular vein

2. the right femoral vein

3. the heart during aspiration

The order in which vessels are raised varies depending on the relationship of the artery to the vein. Two general rules

1, When both the artery and the vein are to be used (as a one point injection) always raise the superficial vessels

2. When both arteries and veins are used from same location ( as a one point injection) always insert the instrument (arterial tube or drainage tube) into the deepest vessel first.

Scalpel use for

Making the incision, opening the artery, or vein

Double point scissor use for

Making the incision preparing ligatures; opening the artery or vein

Aneurysm needle use for

Dissecting fat and fascia; elevating vessels at surface

Bone separator use for

elevate vessels at skin surface

Arterial tubes use for

for insertion into the artery for injection of fluid

Drainage tubes use for

for insertion into the vein for drainage control

Angular Spring Forceps use for

For insertion in the vein for drainage control (in lieu of a drainage tube)

Straight spring forceps use for

Passing ligatures around the vessels

Groove director

Assisting in expansion of the vein for insertion of the drainage device

Incision for the common carotid artery

Supraclavicular (anterior lateral) the incision is made on the clavicle or collar bone. From a point near the sternoclavicular articulation and is directly lateral

Anterior vertical (parallel) the incision is made from a point near the sternoclavicular articulation and is directed upward on the sternocleidomastiod muscle

Posterior vertical (parallel) the incision posterior to the sternocleidomastiod muscle. 2 in below the lobe of the ear and directly downward toward the base of the neck.

Anterior horizontal the incision is made at the base of the neck from point of the sternocleidomastiod muscle and is directly posteriorly

Flap incision (semilunar) This incision is used by the operator when it is necessary to raise the vessels on both the right and left side for injection or drainage.

Slap line. this incision is adaptable to the embalming of females. This incision is made approximately 2 in lateral to the base of the neck on the line where the strap of the under garment crosses the shoulder.

Supraclavicular (anterior lateral)

the incision is made on the clavicle or collar bone. From a point near the sternoclavicular articulation and is directly lateral

Anterior vertical (parallel)

the incision is made from a point near the sternoclavicular articulation and is directed upward on the sternocleidomastiod muscle

Posterior vertical (parallel)

the incision posterior to the sternocleidomastiod muscle. 2 in below the lobe of the ear and directly downward toward the base of the neck.

Anterior horizontal

the incision is made at the base of the neck from point of the sternocleidomastiod muscle and is directly posteriorly

Flap incision (semilunar)

This incision is used by the operator when it is necessary to raise the vessels on both the right and left side for injection or drainage.

Slap line

. this incision is adaptable to the embalming of females. This incision is made approximately 2 in lateral to the base of the neck on the line where the strap of the under garment crosses the shoulder.

Suture

The act of sewing also the completed stitch

Ligature

A thread , cord or wire used for tying vessels, tissues or bones

Subcutaneous

Under the skin

Intradermal surture

A type of suture used to close incision so the suture thread remains entirely under the epidermis. a hidden subcutaneous suture

Baseball suture

The type of stitch seen on a baseball cover, used for vascular or autopsy incisions

worm suture

A method of sewing an incision along the edges without entering the opening whereby the suture becomes invisible and the line of suture becomes depressed making it easier concealment by wax

Basket weave suture

A network of stitches employed to cross borders of a cavity or excision used to anchor fillers and to sustain the tissue in its proper position

Anchor

A material or techique employed to secure tissues or restorative material in a fixed position

Purse string suture

Suture made around the circumference of a circular opening or puncture to close it or to hold the margins in place

Bridge stitch (interrupted)

A temporary suture consisting of individually cut and tied sitches employed to sustain the proper position

In the unautopised body, six arteries are raised what will separately inject the head and the limbs.

Right and Left common carotid arteries

Right and Left axillary (or brachial) arteries

Right and Left femoral (external iliac) arteries

drainage can be taken from each location or the internal jugular vein.

The right internal jugular vein is in direct line with

the right atrium of the heart

The central point of blood drainage in the dead human body

Right atrium of the heart.

The left internal jugular joins

the left subclavian vein to form the left brachiocephalic vein, which crosses to the right side of the chest, joins with the opposite brachiocephalic vein, and forms the superior vena cava

Procedures for Restricted cervical injection

Raise the right common carotid artery

insert arterial tube into the right common carotid directed toward the head

Insert the second into the arterial directed toward the trunk. BE CERTAIN TO KEEP THE STOPCOCK OPEN ON THE TUBE DIRECTED TOWARD THE HEAD.

Insert a drainage device into the right internal jugular vein. internal jugular vein

Raise the left common carotid artery only. Insert a tub into the artery directed toward the head and leave the STOP COCK OPEN

Facial Artery Procedure

Artery can be felt pulsating by touching the inferior margin of the mandible just in front of the angle of the jaw.

Fibers of the playsma muscle have to be opened and by moving the aneurysm needle along the inferior margin of the mandible, the artery is found.

The second artery that can be used to embalm the entire body

Axillary Artery

Incisions for the axillary artery and vein

The arm should be extended (abducted) a little less than 90 degrees from the body. The incision is made parallel to the linear the anterior margin of the hairline of the axilla

Make the incision along the anterior margin of the hairline

Begin the dissection and first locate the axillary vein. This will be a superficial vessel.

Place ligature around the vein and pull the vein away fro the incision and downward.

Go above and behind the vein to locate the artery

Pass two ligatures around the artery

Incise the artery and place the arterial tubes into the vessel

Return to the vein pass a second ligature around the vein and open the vein and insert a drainage tube or forceps toward the heart