Chapter 14: Cavity Embalming

types of purge

stomach purge, lung purge, anal purge, brain purge, and embalming purge

brain purge

Requires fracturing of the cranium, may include gas.  Aspirate and inject via the nostrils through the cribriform plate of the ethmoid bone.

lung purge

Frothy white to pink to red depending on blood content

anal purge

Apply pressure to the abdomen to expel fecal matter.  Allow fecal matter to continue during injection.  Pack the orifice after arterial injection.

stomach purge

 Brown “coffee grounds”, the result of the action of acid and enzymes on blood in the digestive tract.

Embalming Purge

Purge of arterial solution, which exits the vascular system into the stomach, esophagus, or respiratory tract.  Replace lost volume of solution.  If drainage continues, embalming purge is ok.

Post Embalming Purge Prevention Methods

›Thorough aspiration

›Additional cavity fluid in difficult cases

›Hypodermically inject buttocks and walls of cavities

›Re-aspirate those bloated with gas, ship-ins, and prior to dressing

›Pack the nose and throat with cotton.  Remove moist cotton.

›Treat the cranium

›Incise the trachea

The Purpose of Embalming Cavities

Purulent materials, blood, edematous fluids, and unembalmed tissues in the cavity will continue to decompose. Microbes will continue to feed and produce waste gasses and purge. We cannot visually confirm whether internal structures, including the stroma (supporting tissues) and parenchyma (functional tissues) of the organs have received sufficient arterial solution. Arterial distribution will reach the walls of the organs, but not the lumina (empty spaces) inside the organs.

Hydroaspirator

›Water flows through a valve creating a vacuum

›Hose attached to this valve suctions materials into waste water.

Electric Aspirator

• Creates vacuum with an electric motor

• Harder to clear clogs than from hydroaspirator

• Not often found in prep rooms, but good to have as a back-up

older aspiration technologies

hand pump and air pressure machine

Instruments and Devices used for Hydroaspiration

Hydroaspirator, Electric Aspirator, hand pump, air pressure machine, and trocar

Suction Devices used for Hydroaspiration

Hydroaspirator, Electric Aspirator, hand pump, and air pressure machine

Aspiration

Removal of fluids and semi-solids from body cavities via a trocar, attached to a suction machine by a length of hose.  Performs two functions:

1. Makes space so that the body cavities can receive cavity fluid

2. Perforates (makes holes) the organs so that the cavity fluid can enter the lumina and preserve the interior.

Injection

Use of a cavity injector attached to a bottle of cavity fluid to perfuse the fluid over and into the organs of the body cavities. The thoracic, abdominal, pelvic, and even sometimes the cranial cavity are treated.

immediately after arterial embalming

When does aspiration usually take place?

it allows time for arterial solution to further enter the tissues

What does delayed aspiration and cavity embalming do?

partial aspiration

limited aspiration of the abdominal cavity when there is a concern about ascites or gas interfering with arterial distribution

Those that interfere with preservation, i.e. edema, decomposition. Cases where pathogens exits and extended arterial diffusion is needed to sanitize the body.

What conditions might make an embalmer consider delaying aspiration?

trocar

either sanitized between cases and switched between different devices for aspiration and injection or permanently attached to the suction hose and sanitized

Used to treat the gut, where microorganisms live. If not properly sanitized, there is a risk of translocation.

why do we sanitize the trocar?

cranial aspiration

Use a small trocar to puncture the cribriform plate of the skull.

thorax cavity

the heart (slightly of of the midline), the sac that envelops the heart (pericardium), the lungs, the sacs that envelop the lungs (pleura), and the vessels that serve the organs (cardiac arteries and pulmonary arteries and veins)

the right atrium of the heart

the center if drainage

the arch of the aorta

the center of arterial distribution

abdominal cavity contents

Alimentary canal:  Stomach, small intestine, and large intestine (hollow organs)

Other organs:  Liver, pancreas, spleen, and kidneys

pelvic cavity

–Prostate gland and seminal vesicles (males)

–Uterus, ovaries, fallopian tubes, and vagina (females)

–Urinary bladder

the nine divisions of the abdomen

right hypochondriac, epigastric, left hypochondriac, right lumbar, umbilical, left lumber, right iliac, hypogastric, and left iliac

Hypochondriac

Chondria means “cartilage.” In this case, the cartilage beneath (hypo) the ribs. Upper lateral regions.

Epigastric

Referring to the upper abdomen. Superior medial region.

Lumbar

Referring to the region of the spine unsupported by the ribs. Lateral regions.

Umbilical

Belly Button or Navel. The centermost, medial region.

iliac

Referring to the ilium, the large broad bone forming the upper part of each half of the pelvis. Lateral inferior regions.

Hypogastric

referring to the lower abdomen, medial inferior region

So you know where the organs are located and aspirate superficially, deep, and at medium depth

why is the abdomen divided into regions?

Tells you which direction to aspirate/inject so you are sure to treat certain key locations in the cavities

Trocar Linear Guides

Starting point is always

2 inches to the left of the navel, and 2 inches superior, toward the head

If inserted on the right, you would not be able to rotate due to the dense tissue of the liver. Also provides a common starting point for the linear guide.

Why do we insert the trocar where we do?

Right side of the heart

Toward the right earlobe

Stomach

Toward the intersection of the fifth intercostal space and the left midaxillary line. Meaning, toward the left armpit.

Cecum

First part of the large intestine, where decomposition often begins: Toward a point one-fourth of the distance from the right anterior-superior iliac spine to the pubic symphysis. So, take the length of the inguinal ligament, and direct the trocar ¼ of the way from the lateral end.

Urinary Bladder

Toward the pubic symphysis

Make a superficial puncture with a scalpel or trocar at the standard entry point. 

How is partial aspiration done?

Antemortem Subcutaneous Emphysema

Swelling of tissues prior to arterial injection as a result of gas. (Facial tissues and tongue, Thoracic walls, and Scrotum)

Facial swelling can be relieved by channeling

Making incisions in the subcutaneous tissues of the neck to allow gas pockets to migrate.

via aspiration with the trocar tip superficial to prevent damage of vessels

Antemortem Subcutaneous Emphysema can be removed how?

reasons for immediate cavity embalming after arterial injection

For the sake of efficiency

Immediate removal of microorganisms.

Immediate alleviation of pressure that might cause purge

Removal of blood that may cause discolorations

Relief of distention of neck/facial tissues

Process of aspiration

›Be thorough.  Create lots of perforations (holes) through which the cavity fluid can travel.

›Be systematic. 

›Sometimes, there may be an existing breach of the cavity wall that you will chose for aspiration

›A partial autopsy or organ donation may require surface treatment of some viscera and injection of others. Or, you can lance and drain the organs in-situ, then suture and cavity inject

Thoracic

What cavity is treated first?

Abdominal/Abdominopelvic

What cavity is treated second?

heart tap

An alternative drainage method, when your venous drainage site(s) aren’t working

how is the heart tap done?

›Follow the trocar guide for the right side of the heart.  Use the trocar to pierce the right side of the heart.  Look for venous (dark) blood in the aspirated material.

Hydrocele or hernia

–Direct the point of the trocar anterior to the pubic symphysis. 

–Go over the pubic symphysis while still beneath the skin

–Use a cloth wrapped around the scrotum and apply pressure, forcing fluid back into the abdominal cavity.

–Inject undiluted cavity fluid into the scrotum

Cranial aspiration

–Introduce a small trocar into the nostril. 

–Puncture the cribriform plate of the ethmoid bone

–Direct the trocar into the opposite side of the cranial cavity. 

–Treat both sides by using the opposite nostril

–Only a few ounces of cavity fluid can be injected via hypodermic syringe.

–Tightly pack the nostrils to prevent leakage

Injection of Cavity Fluid

›A hose leading to a trocar is affixed at one end of the injector,

›and a bottle of cavity fluid is affixed to the other.

›Evolution injector does not require a hose

›Do not dilute cavity fluid.  It is designed to be used out of the bottle.

›The general rule of thumb is (One bottle (16oz) into the thoracic cavity, one bottle (16oz) into the abdominopelvic cavity)

›Make adjustments based on the size of the body and the amount of material removed via aspiration

Trocar Button

Can be applied by a trocar button applicator or screwdriver

Trocar Site Closure Methods

Trocar button, purse-string, and N-stitch

›Before dressing

›Before shipping out

›After receiving a shipped body

›If decomposition is evident

Re-aspiration is a good standard practice for all cases, but should especially be done when?

causes of purge

›Gas

›Visceral Expansion

›Arterial solution leaking through ulcerated vessels, esophageal varices, dissected aneurysm, or recent surgical incisions

›Ascites and hydrothorax

purge

The postmortem evacuation of any substance from any external orifice of the body as a result of pressure. 

when does purge occur?

before, during, and after embalming

Recommendations for Purge

›Apply massage cream to the face to keep purge exiting the oral cavity from damaging tissues.

›Puncture the abdominal cavity at the usual trocar insertion point.

›Text also recommends making an incision in the lower left inguinal area, right above the inguinal ligament, to drain ascites

›Use of restricted cervical injection.  Embalm the body, purge will result.  Then aspirate the body.  Then set the features and embalm the head.