CHAPTER 9 EMBALMING VESSEL SITES AND SELECTIONS TERMINOLOGY

CHAPTER 9 EMBALMING VESSEL SITES AND SELECTIONS

TERMINOLOGY v One-Point Injection- One artery and one vein is used at the same site. Example: injection from the femoral artery and drainage from the femoral vein. v Split Injection- Only one artery and vein are used, but at different locations. Example: injection from the common carotid artery and drainage from the femoral vein.

TERMINOLOGY v Restricted Cervical Injection- The right jugular vein is used for drainage while injection is in the left and right carotid towards the head and the right carotid towards the trunk. This will be discussed in much more detail later.

TERMINOLOGY v Multi-point Injection- Injection from two or more arteries. Example: injecting the carotid and the femoral to achieve the desired results. v Types are: • Restricted cervical injection • Six-point injection • sectional vascular injection

TERMINOLOGY v Sectional Vascular Embalming- can be used for an autopsied or un-autopsied case. It is used to separately inject a particular body region. The body regions are there vessels are:

TERMINOLOGY v Face and Head: Common carotid artery v Upper Extremity: Subclavian, axillary, brachial artery v Hand: radial or ulnar artery v Lower Extremity: Common iliac, external iliac, femoral artery v Body Trunk: in the un-autopsied body, injection of any major artery toward the trunk region.

TERMINOLOGY v Six-Point Injection: Six arteries are raised to inject the head and limbs. v They are: • right and left common carotid arteries • right and left axillary (or brachial) • right and left femoral (or external iliac)

VESSEL SELECTION v In the unautopsied body the arteries most frequently used for embalming are the: • common carotid • femoral, and • axillary arteries. v Most cases start out as a one-point injection but require additional vessels to be raised to achieve the desired results.

VESSEL SELECTION v How to determine if a one-point injection is enough: • • • inject observe and evaluate if needed perform sectional embalming inject again observe and evaluate again if needed perform some form of supplemental embalming

GENERAL CONSIDERATIONS OF VESSEL SELECTION v The right side of the body is used for several reasons including: • most embalmers are right-handed making it easier to work on the right side of the body, • instruments are inserted easier and are more effective in the right internal jugular vein. (think back to anatomy class-more direct path. )

NERVE CHARACTERISTICS v Nerves are: • • • solid structures with a silvery white sheen that show striations along their surface and do not have a lumen ( an opening) when cut. They do not have blood in them and the vasa vasorum are not visible.

VEIN CHARACTERISTICS v Veins are : • • • thinner than arteries and contain valves that when cut they have a lumen and collapse to create a funnel effect. They are bluish when filled with blood and the vasa vasorum are not visible.

ARTERY CHARACTERISTICS v Arteries have: • • thick walls, are creamy white in appearance, the vasa vasorum can be seen. The lumen of an artery is very pronounced when cut as the walls do not collapse. • They are elastic and can be easily stretched.

SELECTING AN ARTERY v As these questions: • How superficial or deep is the artery? In an obese person the femoral artery could be very deep and hard to secure or in a person who has lost significant weight during the dying process they femoral could be superficial making it an ideal vessel to select. • What structures surround the artery?

SELECTING AN ARTERY v Criteria that should be considered when contemplating an injection site. (mutilation? ) v How close to the aorta is the artery? Remember the closer the vessel to the aorta the better the results. v What is the diametric size of the artery? Is it so small you don’t have a canula to fit in it? Or is it large enough pressure? to be able to use a decent amount of

SELECTING AN ARTERY v Can the body be positioned properly if this artery is used? v Unless you’re trying to get instant fixation of the tissue any artery can be used and the body positioned immediately after injection, such as the axillary.

SELECTING AN ARTERY v Will incisions for the artery be on an exposed body area? v This is why I have never the seen the facial artery used. Also, funeral directors used to ask families to bring in a dress with a high neck line for the women so the incision wouldn’t show. Today, a good embalmer doesn’t neck dress. need to “hide” behind a high

SELECTING AN ARTERY v Can drainage be taken from the vein which accompanies the artery? v An example of where drainage potentially wouldn’t be taken would be the radial and ulnar. The veins are so small that it wouldn’t be worth cutting and would only give you another incision to have to seal.

SELECTION OF THE ARTERY Other factors to include when selecting an artery

AGE OF THE DECEASED v Infants- the carotid artery is the largest and should be selected for that reason. v Elderly- many times the femoral artery is sclerotic so it is not chosen first.

GENDER v What the family chooses for the deceased to wear is a very small factor in choosing a vessel. You should be able to accommodate a family’s choice as well as provide the most complete embalming necessary.

WEIGHT v In obese bodies the femoral artery is very deep and may not be able to be used. v In very thin bodies the SCM can be pronounced and care should be taken when using the carotid the protect the SCM.

FAT DISTRIBUTION v People carry their weight in different areas of their bodies. Be aware that they may require more than 1 injection site to properly embalm the entire body.

DISFIGURATIONS PRESENT v Examples are: • arthritic conditions • tumors • scar tissue v Try to avoid these areas as the vessels that lie beneath them may have some damage to them or simply may be hard to raise.

DISEASE CONDITIONS v Examples include: v Gangrene- Don’t use the vessels where there are signs of gangrene, it is probably a sign that there is poor blood supply. v Burned Tissue- Avoid burned tissue if possible as leakage will be a problem when suturing.

EDEMA, LOCALIZED OR GENERAL v Generalized edema is called anasarca. v When edema is generalized a restricted cervical injection should be used to avoid having to raise several arteries on the body which could lead to leakage problems. v Large quantities of fluid should be injected for generalized edema.

INTERRUPTION OF THE VASCULAR SYSTEM v Mutilation or Trauma: car accidents or accidental death can result in severed arteries. These bodies require more than one point of injection and the several arteries will have to be clamped during the injection.

INTERRUPTION OF THE VASCULAR SYSTEM v Ulceration's: Ruptured blood vessels can be the result of ulceration's. The embalmer may notice that there is a lot of arterial fluid coming out with the blood. If this occurs the embalmer may need to sectionally treat the body.

INTERRUPTION OF THE VASCULAR SYSTEM v Autospies- Depending on the type of autopsy; partial or complete, the embalmer may have to choose which vessels to use.

TRAUMA v Trauma may be present from: • mutilation • accident • surgery

MEDICO-LEGAL REQUIREMENTS v This can include: • • preparation for medical schools international shipping under military contracts coroner or medical examiner v Each of these situations may have written protocol the embalmer must follow.

CAUSE OF DEATH v Example- depending on how a person died you may or may not have all of the arteries available to you for selection.

MANNER OF DEATH v Example- a bullet wound could sever a major artery and make it unavailable for selection. v Example- a natural death of a person could mean that you have all the arteries available to you for selection.

CLOTTING v If an embalmer feels that clots may be present they should use the carotid artery as a starting point for injection and then select subsequent vessels if needed.

FACIAL TISSUE DISTENSION v Always use a restricted cervical injection if facial tissue distension is present or if it becomes an issue.

FACIAL DISCOLORATION v Many times when a person dies from a heart attack the jugular veins are distended, in order to help rid this pressure use the jugular vein for drainage will help clear this tissue.

VOLUME AND STRENGTH ARTERIAL SOLUTION v If the embalmer needs to use a large volume of fluid with a strong solution then a restricted cervical injection should be used to avoid over injection of the fluid to the facial tissue.

SIZE OF THE ARTERY v Use the largest artery available because it will be more elastic and will allow for the use of higher pressure and faster rates of flow which will help the solution distribute more evenly.

ELEVATION AND LIGATION OF VESSELS

THE 10 STEPS TO “RAISE” A VESSEL v 1. Select the instruments and prepare thread you will be using. ( You will probably have a tray will all the instruments you need for the embalming. ) v 2. Locate the vessel by the linear guide. v 3. Make the incision where the vessel in nearest the skin surface. (The closer the vessel is to the surface the easier it will be to work with. )

THE 10 STEPS TO “RAISE” A VESSEL v 4. Make the incision. v 5. Dissect the muscle to get to the vessel, don’t cut it. . v 6. When both the artery and corresponding vein are to be used always raise the superficial vessel first, this will make locating the deeper lying structure easier. • Always insert the instrument into the deeper lying vessel first.

THE 10 STEPS TO “RAISE” A VESSEL v 7. Always use an arterial tube slightly smaller than the opening of the artery that will make the insertion easier and will protect the vessel from breakage. v 8. If clotted material is present, try and remove it before inserting the arterial tube. v 9. Search for the softest portion of the artery to insert the arterial tube.

THE 10 STEPS TO “RAISE” A VESSEL v 10. If the artery is accidently broken the ends must be found and closed before a new arterial tube can be inserted.

INSTRUMENTS v Scalpel- Used for making the incision. v Double-point scissors- Used for making the incision and cutting the ligature. v Aneurysm needle- Used for dissecting fat and fascia; elevating vessels at surface. v Bone Separator- Used for elevating vessels at the skin surface.

INSTRUMENTS v Arterial Tubes- Used for insertion into the artery for injection of the fluid. v Drainage Tube- Used for insertion into the vein for drainage control. v Angular Spring Forceps- Used for insertion into the vein for drainage control. v Straight Spring Forceps- Used for passing ligatures around the vessels.

INSTRUMENTS v Grooved Director- Used for assisting in the expansion of the vein for insertion of the drainage device.

LIGATURE v Ligature is a fancy word for string. v Usually the string that an embalmer uses is heavy and thick and made of linen or cotton. v Many embalmers use dental floss to sew cranial autopsy’s and the right carotid incision when a hidden stitch is used. v The ligature should be 8 to 12 in. in length.

COMMON CAROTID ARTERY

REGIONS SUPPLIED v The head and face if in injection is superior. v The entire body if the injection is inferior.

PRO’S- IT IS: vlarge, veasily raised to the skin surface, velastic, vrarely found to be sclerotic, vthe artery that supplies fluid directly to the head,

CON’S v The head may be over injected. v If leakage occurs, it may be seen. v Some types of instrument may mark the side of the face or jaw line if used improperly. v The incision may be visible with some types of clothing.

INCISION v The most commonly used form of incision is the Anterior Lateral (supraclavicular): The incision is made on the clavicle from a point near the sternoclavicular articulation and is directed laterally. This is pictured on page 165 of your textbook. There is no need to learn the other types of incisions for the common carotid artery.

PROTOCOL FOR RAISING THE CAROTID v 1. Stand at the head of the embalming table. v 2. Turn the head to the left to raise the right common carotid. v 3. Remove the head block, this will give you more area to work with and will avoid having to work around the head block. (NOTE: this is my step 3, not the books suggestion, I think this works better. )

PROTOCOL FOR RAISING THE CAROTID v 4. Make the incision. v 5. Find the SCM muscle at the clavicle. v 6. Raise the internal jugular vein and tie it off. v 7. Go MEDIAL AND DEEP to find the carotid and bring it to the surface, bring two strings around it, cut it, and insert the arterial tube, secure the tube with string.

PROTOCOL FOR RAISING THE CAROTID v Open the vein and insert a drain instrument.

INTERNAL JUGULAR VEIN

PRO’S, IT IS: v large, v the vessel that provides direct drainage from the face and head, v accompanied by the common carotid artery, v close to the superior vena cava allowing easy removal of blood clots.

CON’S v Leakage may be visible. v Drainage instruments if used improperly mark the face. v The incision may be visible with some clothing. v These are the same con’s at the common carotid artery as the incision is made in the same place.

THE RESTRICTED CERVICAL INJECTION v. Procedure: • Raise the right common carotid (rcc) artery and the right internal jugular vein. • Insert an arterial tube into the rcc directed toward the head. Insert a second tube into the artery directed toward the trunk. • Insert a drainage device into the vein. • Raise the left common carotid (lcc) artery and insert a arterial tube toward the head.

FACIAL ARTERY

WHEN USED v In bodies that been autopsied and the carotids or portion of are removed. v In bodies with clotting or sclerosis of the carotid artery.

SUPPLIES FLUID TO THE: v Soft tissue of the face v Upper and lower lips v mouth area v side of the nose v medial tissue of the face v lower eyelid

SUTURING CAN BE DONE WITH: v Super Glue v Dental Floss

AXILLARY ARTERY

REGIONS SUPPLIED v Directed toward the hand it supplies the arm and the hand. v Directed toward the body it supplies everything.

PRO’S v The arterial solution flows directly into the arm and hand. v Close to the face. v It is a superficial vessel.

CON’S v The arm must be extended. v The artery is small to use for injection of the entire body. v The accompanying vein is small. v The facial tissue could be over injected if injection is directed toward the head. v There are numerous branches.

INCISION v The arm is extended from the body. v The incision is made parallel to the linear guide.

AXILLARY VEIN v The vein is found medial and superficial to the axillary artery.

PROTOCOL FOR RAISING THE ARTERY v The steps are the same as the common carotid artery.

BRACHIAL ARTERY

SUPPLIES v Arm v Hand

VEIN v The accompanying vein is the basilic and is difficult to use because it is so small.

INCISION v Anywhere along the upper half of the linear guide.

RADIAL ARTERY

CHARACTERISTICS v Supplies: • Thumb side of the hand. v Location: • Superficial area of the wrist. v Incision: • Parallel to the artery directly on the linear guide about 1 inch above the base of the thumb.

ULNAR ARTERY

CHARACTERISTICS v Supplies: • medial side of the hand. v Incision: • Made parallel to the vessel directly over the linear guide.

FEMORAL ARTERY

SUPPLIES v When directed toward the foot, supplies the leg and foot. v When directed toward the head, supplies the entire body.

PRO’S v Large. v Incision is not visible. v Both sides of the head may receive even distribution. v Accompanied by a large vein for drainage. v No solution has to pass under the body as with the carotid.

PRO’S v The head and arms can be posed with out having to be further manipulated after embalming.

CON’S v May be sclerotic. v May lie deep. v No control of the solution entering the head. v Coagula may be pushed into the head and arms which are viewed. v Other large arteries around it may be mistaken for it.

INCISION v This is basically the same as the common carotid artery except the vein is raised and tied first and then the artery.

FEMORAL VEIN

PRO’S v Large. v Clean method of drainage.

CON’S v The weight of the viscera can restrict drainage from the upper part of the body. v Abdominal pressure can restrict drainage by putting pressure on the vein. v The vein is deep in obese people. v Veins around it can be ruptured easily. v Clots in the rest of the body can be hard to remove.

POPLITEAL ARTERY

CHARACTERISTICS v Supplies: • The area below the knee. v Examples of when it is used: • mutilated bodies • accidental deaths • arthritic bodies v The accompanying vein is not used.

CHARACTERISTICS v Incision: • Down the center of the Popliteal space parallel to the artery or • Just superior to the Popliteal space.

ANTERIOR AND POSTERIOR TIBIAL ARTERIES

CHARACTERISTICS v Supplies: • foot v Location: • they are deep making them hard to find.

EXTERNAL AND INTERNAL ILIAC ARTERY

CHARACTERISTICS v In the autopsied body the external iliac artery supplies solution to the lower extremity and the anterior abdominal wall. v In the autopsied body the internal iliac artery supplies solution to the gluteal and the peroneal regions.

v I am skipping : • Abdominal Aorta and Thoracic Aorta • Inferior Vena Cava • Right Atrium of the Heart v It is extremely unlikely you will ever need to use these when embalming and if you do ask someone to help you that knows what they are doing.

MAKING THE INCISION

v The most common incision is the transverse incision. v As soon as you see the lumen STOP CUTTING!

CHARACTERISTICS