embalm II ch 14 cavity embalming

What are the two steps of cavity embalming?

(1) Aspiration (removal) of contents of hollow organs and cavities and perforation of solid visceral organs.

(2) Injection of a strong preservation/disinfection chemical

What are some times where you may not cavity embalm remains?

• When the body is bequeathed to a medical school-where the school permits vascular preparation of the body for viewing by the family and public

• When a hospital allows the body to be arterially embalming prior to a postmortem examination-autopsy

Three things that cavity embalming treats

(1) Treats the contents of the hollow viscera

(2) Walls of the visceral organs not embalmed by arterial injection

(3) The contents of the spaces between the visceral organs and the walls of the cavities.

What may be aspirated in the Lungs, Trachea, Bronchi

(1) Blood

(2) Edema

(3) Purulent material

(4) gases

What may be aspirated in the Stomach

(1) Hydrochloric acid

(2) Undigested food

(3) Blood

(4) Gases

What may be aspirated in the Small intestine

(1) Gases

(2) Undigested foods

(3) Partially digested foods

(4) Blood

What may be aspirated in the Large intestine

(1) Gases

(2) Fecal material

(3) Blood

What may be aspirated in the Urinary bladder

(1) Urine

(2) Pustular material

(3) Blood

What may be aspirated in the Gallbladder

Bile

What may be aspirated in the Pelvis of the kidney

(1) Urine

(2) Pustular material

(3) blood

What may be aspirated in the Heart , Inferior vena cava, portal veins

Blood

Stomach Purge

Liquids, semisolids, dark brown "coffee ground" appearance. odor and acid pH

From the Nose/mouth

Lung Purge

Frothy; any blood present is red in color, little odor

from the Nose/mouth

Brain Purge

Gases can move into tissues of the eye, fractures can cause blood to purge from the ears, creamy white semisolid brain matter may exit through a fracture or the nasal passage

-Nose/ear/eyelids

When should you generally always consider treating the cranium?

In preparation of the unautopsied stillborn child or infant as their brain can decompose very rapidly. Use a large hypodermic needle for treatment.

Hydroaspirator

Installed on a cold water line preferably over a flush sink. When water is turned on, a vacuum is created. This depends on water pressure to operate. A vacuum breaker is normally a part of the aspirator and prevents against backflow. A sound change indicates that the hydroaspirator has become clogged and water then reverses going into the body.

Electric Aspirator

Contains an electric motor with an encased impeller. Impeller creates suction. A small waterline may provide lubricant for the impeller. Usually more expensive and requires more maintenance than a hydroaspirator. Preferred for areas with low water pressure. May have an attachment so you can add a disinfectant to the contents being aspirated.

Hand Pump

Historical device used rarely today. Used to remove air or force air into an enclosed airtight container. Drawing the air out of the container creates suction. A glass jar with a gooseneck (rubber stopper) was used with a hand pump. Stopper has two openings for hose attachments. One hose allows air movement out of the jar, second leads to a trocar.

Air Pressure Machine

-Historical.

Works on the same principle as the hand pump. Must use jars specifically made for aspiration as there is a danger of glass implosion. Jars are emptied into the sewer, or the contents of jars can be treated by disinfectants prior to being disposed of.

Trocar

A long hollow needle (metal tube) with a fixed or removable sharp point that is available in varying lengths or bores. Standard is 18" long, 5/16ths bore for adults to aspirate abdomen and thorax.

Infant Trocar

12" in length and 1/4 in bore. Used for cavity treatment in children and infants. Hypodermic and cranial injection in adults.

Nasal Tube Aspirator

10" - 90 degree curve - 3/16"bore. Used for aspiration of nasal, oral and cranial cavities. Very small board that is easily clogged. Placed through nasal opening or between lips

Autopsy Aspirator

8"-10" long - 3/8" bore. Used for aspiration of the cavities of the autopsied body and has a number of openings to prevent clogging. Can be set for "hands-free" use while body is being embalmed and is non-clogging so you can keep your attention on what you're doing.

Nine Region Plane

Right Hypochondriac - Epigastric - Left Hypochondriac

Right Lumbar - Umbilical - Left Lumbar

Right Inguinal Iliac - Hypogastric - Left Inguinal Iliac

Right Hypochondriac

(1) Part of the liver

(2) Part of the right kidney

(3) Greater omentum

(4) Coils of small intestine

(5) Gallbladder

Epigastric

(1) Stomach including cardiac and pyloric openings

(2) Portion of liver

(3) Duodenum

(4) Pancreas

(5) Suprarenal glands and parts of kidneys

(6) Greater omentum

Left Hypochondriac

(1) Part of the liver

(2) Stomach, fundus and cardiac region

(3) Spleen

(4) Tail of the pancreas

(5) Left colic splenic flexure

(6) Part of left kidney

(7) Greater omentum

Right Lumbar

(1) Lower portion of liver

(2) Ascending colon

(3) Part of right kidney

(4) Coils of small intestine

(5) Greater omentum

(6) Right colic (hepatic) flexure

Umbilical

(1) Transverse colon

(2) Part of body kidneys

(3) Part of duodenum

(4) Coils of small intestine

(5) Greater omentum

(6) Bifurcation of the abdominal aorta and inferior vena cava

Left Lumbar

(1) Part of left kidney

(2) Descending colon

(3) Coils of small intestine

(4) Greater omentum

Right Inguinal (Iliac)

(1) Cecum

(2) Appendix

(3) Part of ascending colon

(4) Coils of small intestine

(5) Greater omentum

Hypogastric

(1) Bladder in adults if distended

(2) Uterus during pregnancy

(3) Coils of small intestine

(4) Greater omentum

Left Inguinal (Iliac)

(1) Part of descending colon

(2) Sigmoid colon

(3) Coils of small intestine

(4) Greater omentum

Quadrant Method

Aka: Four Region Plane.

A horizontal line is drawn from the left to right through the umbilicus. A vertical line is drawn down the midline of the body

Trocar Guides

the main guides are to reach

(1) Stomach

(2) Cecum

(3) Urinary Bladder

(4) Heart

Insertion Point

2 inches to the left and 2 inches superior to the navel

Guide for the Right Side of the Heart

Direct the trocar to intersect a line drawn from the left anterior - superior iliac spine and the right earlobe. After the trocar has been passed through the diaphragm, depress the point and enter the heart

Guide for the Stomach

Direct the trocar point toward the intersection of the fifth intercostal space entering the left midaxillary line (established by extending a line from the center of the medial base of the axillary space inferiorly along the rib cage); continue until the trocar enters the stomach

Guide for the Cecum

Direct the trocar toward a point one-fourth of the distance from the right anterior iliac spine to the pubic symphysis; keep the point of the trocar well up near the abdominal wall until within 4 inches of the right anterior-superior iliac spine; then dip the point 2 inches and insert it forward into the colon

Guide for the Urinary Bladder

Keep the point near the abdominal wall directing the trocar to the median line of the pubic bone (symphysis pubis) until the point touches the bone. Retract the trocar slightly, depress the point slightly, and insert into the urinary bladder

When should you relieve abdominal pressure if the abdomen is tightly distended?

Prior to or during arterial injection

Relieving Abdominal Pressure

(1) Use a scalpel and puncture the abdomen at standard point of trocar entry. Insert a trocar or blunt instrument into the cavity and release the gases or edema (May be easier to make the incision in the lower area of the abdomen in the right or left inguinal area of the hypogastric region as edema will be able to gravitate easier as well as perhaps needing to cut the transverse colon to let out gas)

(2) Make an incision in the abdominal wall. Dissect into the abdominal cavity ( A portion of the large intestine can be incised if gas is a problem. Cover opening with cotton or gauze saturated with a disinfectant so microbes are not aerosoled

Method 1 is much cleaner and found to be generally more effective in relieving abdominal pressure (gas or edema) prior to or during arterial injection

Subcutaneous Emphysema

dissension of the tissues beneath the skin by gas or air; an antemortem condition brought about by a surgical procedure or trauma; e.g.: CPR that breaks a rib which punctures a lung, allowing air to escape into the body cavity.

Guide for Relieving Subcutaneous Emphysema

Insert the trocar into the abdomen at the standard point of entry, then direct the point through the diaphragm, keeping the point just under the rib cage so as not to damage any of the large vessels

Two Time Periods For Cavity Treatment

(1) Immediately following arterial injection

(2) Several hours after arterial injection

Immediately following arterial injection

(1) Large numbers of microbes are removed asap.

(2) Reduces translocation of microbes.

(3) Minimizes purge as a result of microbial activity.

(4) Minimizes purge as a result of decomp.

(5) Eliminates bacterial medium in hollow viscera.
(6) Removes blood and reduces chance of embalmers gray.

(7) Decreases swelling due to hydrothorax

Several hours after arterial injection

This delay allows better diffusion of arterial chemical especially if you injected the last quarter gallon of solution under closed drainage. Makes it easier to pierce organs since some preservation has taken place.

Begin Aspirating

Prior to suturing incisions that were made for the arterial injection. Aspirating takes the pressure of the vascular system and thus decreases the possibility of leakage from the incision should small vessels leak

Surgical Drainage Openings

Should be closed by suture or trocar button prior to aspiration of the cavities

Direct Incision Method

-Surgical incisions

Uses this incision to lance and drain the various organs and aspirate the cavity. Cavity fluid can be injected after the body is re-sutured. this method is unsanitary and time consuming

Aspirating the Thoracic Cavity

Good point at which to begin aspiration is the right side of the heart. Aspirate the anterior chambers of the right and left pleural cavities. Direct trocar a little lower and pierce the central portions of the lungs and the heart. Finally, aspirate the deep areas of the pleural cavities. If hydrothorax is present, edematous liquids will be found.

Aspirating the Abdominal Cavity

Keep instrument in constant motion as the small intestine has a tendency to cling to small holes in the tip of the trocar. The liver is very difficult to preserve, numerous passes with the trocar should be made. Large intestine should be adequately pierced to allow escape of gases - place gloved hand on the abdominal wall and apply pressure. Pass tip of trocar to a bony part so that it pierces hollow organs. May also insert the trocar in the right or left inguinal region of the abdomen as some embalmers say long passes from this point of insertion pierce the intestines better

Treatment for the Scrotum

Trocar does not need to be inserted into the scrotum on every case. Cavity fluid should be injected into the shaft of the penis and scrotum if arterial distribution is not sufficient. To enter the scrotum direct the point of the trocar to the most anterior portion of the pubic bone draw back slightly on the trocar and direct the point over the top of the symphysis pubis into the scrotum. In the event of hydrocele, make several such passes into the scrotum (channeling) and be careful not to puncture the scrotum. Place a cloth around the scrotum and force water into the pelvis. Inject cavity fluid. Hernia in the scrotum can be difficult to treat. You may utilize the trocar to pull the intestine back into place which will make things much easier in the long run.

Aspirating the Cranial Cavity

Point of entry is either nostril. A small trocar is pushed through the cribriform plate of the ethmoid bone and enters the anterior portion of the cranial cavity. You can't get the trocar into the posterior portion. Any gases must be removed from here. Inject only a few ounces of cavity fluid using a hypodermic syringe with a long needle. Pack nostrils tightly to prevent leakage.

What is the rule of thumb for injecting cavity fluid? How many bottles for how many cavities?

On average a 150lb body should have 16 ounces injected into EACH of the the three major cavities (3 BOTTLES). Larger bodies should get more, smaller bodies should get less.

Methods of Closing Trocar Openings

Purse string or "N" (reverse stitch). You can use a bow to close in the event you need to reopen. Place stitch after aspiration prior to injection. Pull suture tightly closed after injection to prevent fumes.

-Trocar button: More complete closure, easy to reopen

When to Reaspirate

(1) When prior to dressing the trocar button is removed and a noticeable amount of gas appears to be present in the abdomen.

(2) When the body is to be transported to another funeral establishment (Ship-out)

(3) When the body is received from another funeral establishment (Ship-in)

(4) When decomposition is present.

(5) In the case of recent abdominal surgery

(6) When the embalmer is dealing with an obese body

(7) When the body shows evidence of gas-distension of the veins of the neck or backs of the hands.

(8) When purge is present.

(9) When death involved blood infection or infection of the abdominal cavity (e.g. sepsis, peritonitis, or pneumonia)

(10) When death occurred from drowning.

(11) In the case of bodies with ascites.