Advanced Embalming Procedures - MSFS 360

Who typically performs autopsies?

Forensic pathologist

Who typically orders autopsies?

Coroner/Medical Examiner

Why perform an autopsy?

To determine cause, manner, time of death; recovery, ID, preservation of evidence, provision of factual and objective info for legal authorities

When should autopsies be performed?

All sudden deaths not caused by readily recognized disease, suspicious circumstances (drugs, alcohol, etc.), violence/trauma (suicides), fetal/infant deaths, stillbirths, all operative/perioperative deaths, individual can’t be ID’d, uncertain to to be reported to coroner

Work practice controls to consider

Bone edges are sharp, be aware of instrument placement, practice continuous aspiration of cavity, avoid high water pressure, clamp leaking vessels

Autopsy embalming analysis

Mostly same as normal body, fluid strength stronger than average, rigor may be present, but most likely has passed; hemolysis common in refrigerated bodies, dyes show in shell embalming, pressure/rate of flow are different (slower), open drainage

Complete autopsy

Most cavities removed including cranial cav, possible eye enucleation/tissue removed, neck organs (tongue, larynx, thyroid, etc.), thoracic/abdominal organs, pelvic organs, removal of spinal cord in some cases

Partial autopsy

Only 1 body cavity opened and used to examine specific organ (either cranial, thoracic, or abdominopelvic cavity); used when possible cause of death known, funding is limited, person granting permission limited autopsy

Autopsy incisions

“Y” incision is most common; “U” incision used by some on females but RARE

Dorsal Postmortem Approach

Incision through back to see spinal cord and nerve endings

Cranial incision for autopsies

Runs from ear to ear posteriorly

Autopsied body - Step by step

Look at written notes

Injecting lower extremities - Autopsy

If possible, use terminal end of abdominal aorta; if not possible, locate common then external iliac arteries

Leg injection - Autopsy

Usually about ½ gallon per leg is sufficient (but use own personal observations to properly determine); pathological conditions, sclerosis, leakage, postmortem conditions

Injecting upper extremities - Autopsy

If arch of aorta is present, use aortic branches (L subclavian - be careful w/ brachiocephalic on R); if not possible, raise axillary arteries and inject each arm

Injecting the head - Autopsy

Use common carotid arteries, Y cannula can be used w/ caution; if injecting sides of head separately, be sure to clamp off side not being injected (L, then R side)

Injecting the head - Autopsy (cont.)

If common carotids not available, use external carotids; clamp all leaking vessels using small spring clamps for cranial autopsy

Cranial autopsy

Look at written notes

Aneurysm

Bulge/dilation in wall of blood vessel, typically an artery; can resemble berry/balloon-like structure

Aneurysm - Possible complications

Rupture of aneurysm is most serious concern, distribution of arterial fluid hampered due to rupture and pressure on vessels, may be eye swelling if in brain

Aneurysm - Embalming options

Multi-point injection, may be necessary to aspirate blood from rupture, pack nasal cavities if there’s cranial purge, same w/ drainage from ears (pack w/ cotton and dry powder); no special chemicals needed but watch for leakage

Cirrhosis

End-stage of chronic liver disease that occurs when healthy liver tissue is replaced by scar tissue, preventing liver from functioning properly; result of other stages of liver damage (caused by Hep B and C, chronic alcohol use, other medical illnesses/issues)

Cirrhosis - Possible complications

Liver may be enlarged, causing distention; ascites/edema may be present, circulation to and from liver may be difficult (treat w/ cavity fluid), jaundice may be present

Cirrhosis - Embalming options

Use jaundice fluid if necessary, wash surface w/ soapy water and cloth, preservation is most important; if discoloration does occur, use heavier cosmetics

Jaundice fluids

Contain agents that bleach and flush bilirubin, glutaraldehyde is preferred alternative to formaldehyde

Jaundice fluids - Premium jaundice

Co-injection fluid that should be injected at rate of 4-8 oz/gal of diluted arterial fluid

Jaundice fluids - Color Guard 1

Jaundice fluid that reacts w/ bilirubin to change its color from yellow to red/rosy; doesn’t contain preservative chemicals, so it should be used w/ a low-moderate index arterial fluid

Jaundice fluids - Jaun-dial

Jaundice fluid that some say provides firming and even dye take

Creutzfeldt-Jakob Disease (CJD)

Rare, fatal brain disease caused by the accumulation of abnormal proteins called prions in brain

CJD diagnosis

Brain biopsy, spinal tap, EEG, MRI; may not be diagnosed until onset of symptoms; typically leads to death w/in 1 year of symptom onset

Sporadic CJD

Most cases (85%) occur spontaneously w/out known cause

Variant CJD (vCJD)

Caused by eating contaminated beef from cattle w/ bovine spongiform encephalopathy (BSE/”mad cow disease”); contagious

Familial CJD

Inherited from genetic mutation

Iatrogenic CJD

Acquired through medical procedures, such as corneal transplants/contaminated surgical instruments; contagious

CJD - Possible complications

Prions can have incubation period of 10 years, may be present in cases w/ history of premature senility, blood may be infectious, prions extremely resistant to heat and chemical disinfection, brain contains highest concentration of infectious agents (don’t aspirate brain!)

CJD specialized disinfection

For inactivation of prions, use bleach/sodium hydroxide solutions in combo w/ autoclaving where possible

CJD - Embalming options

Use of specialized solutions (glutaraldehyde/phenol-based solutions for arterial and cavity), prion inactivation (cavity fluids in sodium hydroxide pellets/undiluted bleach), instrument use (use disposable when possible); avoid cavity embalming?; cranium treated w/ highly concentrated embalming fluid/powder/gel if autopsied

Diabetes mellitus

Chronic disease that occurs when body doesn’t produce enough insulin/can’t use insulin properly; results in abnormally high levels of blood sugar (glucose) in body - Type 1, 2, and gestational diabetes

Diabetes mellitus - Possible complications

Poor fluid distribution due to poor circulation/arteriosclerosis, potential soft/enlarged liver, potential jaundice, skin lesions/gangrene in feet/legs, potential accumulation of waste/high acidity in blood, blood may coagulate quickly, obesity, tissue firmness doesn’t usually occur (high fluid retention, etc.), skin may be darker that doesn’t lighten w/ embalming, kidney failure common

Diabetes mellitus - Embalming options

Multi-point injection may be necessary, carotid/jugular recommended, higher than normal concentration and volume of fluid recommended, higher than normal pressure/use of pulsation may improve distribution, use 2 bottles of cavity fluid and re-aspirate

Diabetes mellitus - Embalming options (cont.)

Treat surface lesions w/ topical preservative and cover w/ cotton/wrap, use phenol/bleaching agents on visible discolorations, use humectants/pre-injection w/ arterial fluid if dehydrated; if edema present, use co-injection instead

Waterless embalming

Embalming without water in arterial solution; good for decomp, drowning, anasarca, obesity, or normal cases

Waterless embalming advantages

Maximum amount of preservation w/ minimum amount of solution, doesn’t add to secondary dilution, strong preservation and disinfection qualities

Waterless embalming disadvantage

Expensive

Waterless embalming - Head freeze

Good for head trauma (moderate to massive); advantages are max. preservation w/ min. fluid, strong preservation/disinfection/drying qualities, limits distention to face, creates excellent foundation for RA; disadvantage is could stain head red if using fluid w/ active dye

Waterless embalming - Restricted cervical injection

Solution is 2 bottles arterial fluid, 4 bottles co-injection, 2 bottles water conditioner; high index fluid injected straight to head, inject body w/ needed fluid, then inject L —> R head

Long bone (leg and arm) donation

The surgical recovery of long bones from a deceased donor to be used for transplants in living recipients; grafts can prevent amputations, reinforce areas weakened by cancer/trauma, and restore structure/mobility; recovery performed by trained professionals after death

Bones harvested in long done donation

Femur, tibia, fibula, humerus, radius, ulna, scapula, patella, calcaneus (heel bone), bones from pelvis (iliac crest)

Long bone donation - Pre-embalming

Clean/bathe body as normal, disinfect and clean mouth/nose/eyes (if not enucleated) as normal, set features as normal

Long bone donation - Embalming option #1 (restricted cervical)

Remove all sutures and open all procurement incisions, remove any prosthetic devices if they interfere w/ locating/injecting arteries, locate arteries for injection, raise L and R carotids for injection of head/trunk; don’t use pre-injection and make arterial fluid stronger than normal for trunk/limbs

Long bone donation - Embalming option #1 (legs/feet)

Inject legs w/ femoral artery and start as high on legs as possible; clamp vessels that have been cut during procurement and are leaking (if femoral artery cut, inject below cut); if lower legs/feet don’t receive fluid, anterior/posterior tibials can be injected; if feet don’t receive fluid, raise/inject dorsalis pedis or hypo inject using needle/syringe or trocar

Long bone donation - Embalming option #1 (arms/hands)

Can be injected using axillary/brachial arteries; if hands don’t receive enough fluid, radial artery can be injected

Long bone donation - Embalming option #1 (trunk)

Can be injected through femoral/subclavian/carotid artery

Long bone donation - Embalming option #1 (head)

Inject through carotids; solution for head doesn’t need to be as strong as solution for trunk/limbs

Long bone donation - Embalming option #1 (after injection)

Allow body to sit and drain for as long as possible, dry all tissue in arms and legs, replace prosthetic devices if they were removed, coat tissues w/ preservative, absorbent product, or hardening compound (be generous w/ powders), suture incisions w/ tight suture and wash entire body, aspirate/inject cavities as normal, coat all incision lines w/ sealer and cotton, cover cotton w/ strip of plastic sealed on all sides by wide tape, dress body in rubber/plastic undergarments, dress and casket

Long bone donation - Embalming option #2 (one-point)

Raise R carotid after cleaning/disinfecting and setting facial features; mix arterial solution for trunk, arms, and legs to be stronger than normal; don’t use pre-injection

Long bone donation - Embalming option #2 (during injection)

Inject carotids downwards using the stronger arterial solution, observe arms/hands/legs/feet; if these areas don’t receive enough fluid, either open all incision and inject arteries in different spots or hypo inject limbs (lazy); inject head through R carotid using weaker solution; if L side of head doesn’t receive enough fluid, raise and inject L carotid

Long bone donation - Embalming option #2 (after injection)

Wash entire body, aspirate/inject cavities as normal, make small opening in lowest part of incision lines around legs/arms and insert blunt trocar and aspirate any accumulated fluid; allow body to sit and drain for as long as possible, then aspirate any fluid using previously used opening; suture incision closed and wash area; coat incision lines w/ sealer and cotton, cover cotton w/ strip of plastic sealed w/ wide tape, dress body in rubber/plastic undergarments, dress and casket

National Organ Procurement and Transplantation Network (OPTN)

Federally mandated system established by National Organ Transplant Act (NOTA) of 1984; nationwide network of transplant hospitals, organ procurement organizations (OPOs), and labs that share data and coordinate fair distribution of organs; ensure that donated organs are allocated based on medical need, compatibility, and fairness; sets policies/rules for how organs are matched and distributed across country

United Network for Organ Sharing (UNOS)

Nonprofit org. that operates under contract w/ fed. gov. to run OPTN; maintain national organ waiting list database, making matches between donros and recipeients in real time; develop and enforce transplant policies, collect and analyze data, provide education to professionals and public

Revised Anatomical Gift Act

Allows anyone 18+ y/o, upon their death, to donate their organs and/or tissues for medical purposes; if deceased isn’t registered donor, NOK/authorizing party must consent/deny to donate; donor released to FH after procurement for final disposition

Organ/tissue donors on ventilators

Individuals on ventilators and brain dead are potential donors for organs, must have blood and oxygen still circulating to maintain organ viability; those not on ventilator at time of death can be potential tissue donors for bone, skin, cartilage, blood vessels, etc.

Full median sternotomy

Incision from xyphoid process to pubic bone; U or V incision (both allow for full access to organs during recovery)

Embalming for organ donation

Utilize large incisions made during recovery process; vast vascular disruption and disfigurement that comes from organ/tissue removal; extra steps needed to ensure preservation of tissues and remaining organs

Embalming for organ donation - Arms and shoulders

Inject subclavians

Embalming for organ donation - Head

Inject L and R common carotids; if brachiocephalic still intact at aortic arch, R shoulder/arm and R side of head can be injected at same time

Embalming for organ donation - Abdominal aorta

If abdominal aorta can be utilized, embalmer can embalm trunk walls and lower extremities at same time; if abdominal aorta not viable, use common iliacs

Embalming for organ donation - Drainage

If aorta exposed, superior/inferior vena cava can be utilized for drainage during injection; accompanying veins at injection points can also be utilized during injection; excessive blood and fluid drainage should be aspirated away to reduce fumes; external incisions may be needed to locate arteries nearest to insufficiently embalmed areas

Embalming for organ donation - Post embalming

Surface and hypodermic embalming should be utilized for optimal preservation; cavity injection should be done after trunk of body sutured shut; use baseball suture w/ intermediate locking using tissue gathering forceps

Edema

Abnormal collection of fluid in tissue spaces, serous cavities, or both; found in individual cells (intracellular), between spaces (intercellular), and w/in body cavities; can be localized or generalized

Body moisture content - Edema

Typically said to exist where an excess of 10% fluid is present; normal body moisture content is 55-65%

Predisposing factors for edema

Congestive Heart Failure, cirrhosis of liver, alcoholism, nephritis, renal failure, lymphatic obstruction, 1st and 2nd degree burns, vascular disease, poisons, CO poisoning, steroid therapy, allergic/inflammatory reactions, malnutrition, trauma, extended drug therapy, venous obstruction

Cellular (solid) edema

Occurs when abnormal amount of interstitial fluid passes into and is retained by cell (intracellular); edema w/in body cells, tissues swollen and firm

Cellular (solid) edema - Challenges

Swollen tissues, difficult preservation (doesn’t respond to embalming treatment)

Cellular (solid) edema - Treatment

Must be excised from tissues for reduction (when facial tissues affected, excision of deep tissues after embalming is a restorative method)

Intracellular (pitting) edema

Fluids accumulate between cells of body; causes indentation/pit to remain in tissue when applying pressure to the skin; can be drained from tissues into circulatory system and removed

Intracellular (pitting) edema - Challenges

Distentions, fluid dilution, difficult preservation

Intracellular (pitting) edema - Treatment

Strong arterial solution and co-injection fluids

Anasarca

Severe, generalized, body-wide edema (massive edema); brought on when there’s fluid build-up in tissue

Anasarca - Challenges

Increased rate of decomp from presence of body moisture, excessive fluid causes secondary dilution of solution to increase, reduces ability of solution to dry/sanitize/preserve tissues (~4% TDS or more)

Anasarca - Treatment

Inject solution w/ sufficient strength and volume to counteract secondary dilution; knowing underlying cause is helpful (ex. renal failure causes nitrogenous waste)

Anasarca - Emaciated bodies

Use RCI to avoid over-dehydration of face/features; inject trunk w/ hypertonic solution

Anasarca - Jaundice edema

Use RCI w/ waterless solution to embalm head and large volumes of strong arterial for trunk; hypodermic injection can be used to treat areas not receiving sufficient solution

Anasarca - Head/facial feature distention

Elevate head and shoulders, hypertonic solution will draw edema from tissues into circulatory system, can use channeling method during cavity embalming (direct trocar into affected areas); fluid will drain from face/scalp/neck into thoracic cavities

Anasarca - Drainage

R internal jugular or from both R/L jugulars; continuous drainage encourages removal of edema fluids

Anasarca - Rate of flow

Begin at slow rate; as distribution is established, increase rate to ensure good distribution

Anasarca - Interrupted injection

Periodically stop injection to allow physical exchanges to occur (let fluid move into capillaries and into tissue spaces to preserve); massage and squeeze from distal site (hands and feet) toward heart to encourage edema fluid to move from veins into blood drainage

Ascites

Abnormal accumulation of serous fluid in peritoneal cavity; may be undetected until beginning of aspiration (clear/cloudy fluid) or can be noticeable w/ distended abdominal cavity; edema in abdomen and won’t affect solution dilution/blood drainage (will dilute cavity fluid)

Ascites - Pressure

Pressure in abdominal cavity may have enough pressure to interfere w/ distribution and blood drainage (can’t remove w/ vascular embalming)

Ascites - Techniques to relieve pressure

Use scalpel to make small incision in cavity and insert drain tube (can use trocar w/ tip removed), make incision in inguinal/hypogastric area (lower point so liquid will drain from cavity), insert trocar under wall of cavity and pierce transverse colon to release gases/liquids (use attached aspirating hose)

Hydrothorax

Abnormal accumulation of fluid in thoracic cavity (space between wall, cavity, and lung), can be expected w/ deaths from heart disease/pneumonia, distention in neck common, neck/face can exhibit intense livor mortis after death

Hydrothorax - Embalming

Use carotid artery and drain from jugular; can use femoral, but may restrict solution to head/upper extremities if fluid is present; may need to use multiple injection sites; to remove fluids after embalming, direct trocar to posterior portions of thorax (fluids gravitate there)

Hydrocele

Abnormal accumulation of fluids in a saclike structure, especially the scrotal sac (scrotum gets insufficient fluids - area for decomp to set in)

Hydrocele - Treatment

Usually treated during aspiration and injection of cavity; insert trocar over pubic symphysis and pubic bone (enter both sides of scrotum), apply pressure to force fluids through channels made w/ trocar, fill w/ cavity fluid; don’t puncture scrotum w/ trocar (use button/suture if it does happen)

Hydrocele - Wicking treatment

Make several small incisions; use forceps and place long strips of cotton into incision holes, leaving part of strip hanging out; cotton will wick fluids and drain off end of strip, can use pressure to help fluid come out; once fluid is relieved, use trocar button to seal incision/suture; recommended to use plastic garments on body after

Hydrocephalus

Abnormal accumulation of CSF w/in ventricles of brain, can happen at any age; causes include bacterial meningitis, lesions, tumors, stroke, traumatic brain injury; infant hydrocephalus is congenital

Hydrocephalus - Treatment

Necessary to drain some of this fluid in adults/unautopsied infants (can cause rapid decomp in brain and fluid in cranial cavity); after embalming, use long hypodermic syringe; pass through nostril and direct through anterior portion of cribriform plate of ethmoid bone (draw back plunger to draw out fluids), use undiluted cavity fluid/phenol and inject through same area, pack nostrils to prevent leakage, watch for major head shrinkage

Hydropericardium

Abnormal accumulation of fluid w/in pericardial sac; may cause pressure and restrict circulation; treatment is trocar during pre-embalming (caution - vessel puncture)

Edema - In legs only

Use femoral artery, may need to treat areas by injecting high index fluid/cavity fluid w/ hypovalve/infant trocar (calf is good area to inject); can coat in autopsy/embalming gel, wrap in plastic (cellophane)/use plastic garments w/ drying powder

Edema - Tissue blebs/blisters

Lance blisters (weeping will take place for some time), use cavity pack to cauterize area and wait to dry, wrap in plastic (cellophane) or use plastic garments (or both)