PREPARATION OF AUTOPSIED BODIES AND WHAT IS THE PROPER TREATMENT AND DISPOSITION OF THE VISCERA

PREPARATION OF AUTOPSIED BODIES AND WHAT IS THE PROPER TREATMENT AND DISPOSITION OF THE VISCERA

OBJECTIVES

Knowing and understanding the purposes of an Autopsy Recognizing the types of AutopsiesComplying with work practice controls

OBJECTIVESPreparation partial autopsy complete autopsyOBJECTIVESEmbalmingraising vessels, hypodermic treatment, drying tissue, suturing OBJECTIVES Viscera Proper treatment Disposition of the viscera

Autopsy purposesAn autopsy necropsy or postmortem is an examination of the dead human body.There are four main types of autopsies Medico-Legal autopsy or forensic or coroner's Clinical or Pathological Anatomical or academic Virtual or medical imaging

Autopsy purposesAmong the four main types of autopsies, each one is performed for certain purposes.Autopsy purposesThe types of autopsies we are most likely to see in the mortuary profession are the medico-legal autopsy or forensic or coroner's autopsies, clinical or pathological autopsies.

Autopsy purposesWith the virtual or medical imaging autopsies, we as morticians would never know it was performed. This imaging autopsy is performed to see where and if something is placed within the decedent.Autopsy types Medico-Legal or Forensic, , andAutopsy purposesAutopsies are divided into two categoriesPartial autopsyComplete

Partial AutopsyGenerally only one body cavity is opened to examine one specific item when a partial autopsy is done.

Complete AutopsyThe medico-Legal or hospital autopsy can be either partial or complete

The forensic, coroner's or medical examiner autopsies are generally complete autopsies.Autopsy purposesMedico-Legal autopsy or forensic or coroner's autopsies Seek to find the cause and manner of death and to identify the decedent. They are generally performed, as prescribed by applicable law, in cases of violent, suspicious or sudden deaths, deaths without medical assistance or during surgical procedures [1].

Autopsy purposesClinical or PathologicalPerformed to diagnose a particular disease or for research purposes. They aim to determine, clarify, or confirm medical diagnoses that remained unknown or unclear prior to the patient's death.Autopsy purposesAnatomical or Academic Performed by students of anatomy for study purpose only.

Autopsy purposesVirtual or Medical Imaging

Performed utilizing imaging technology only, primarily magnetic resonance imaging (MRI) and computed tomography (CT).The Medico-Legal or hospital autopsy is obtained from the person with the proper authority to take charge of the body after death. When a family member request that an autopsy should be performed, sometimes there is a fee involved that must be paid prior to the autopsy. In some instances the autopsy will be performed in your funeral establishment. The Medico-Legal or hospital autopsyWhen this type of autopsy is ordered, it is to determine: When doctors have not made a firm diagnosis.When death follows unexpected medical complications.When death follows the use of an experimental drug or device, a new procedure, or unusual therapy. The Medico-Legal or hospital autopsyWhen death follows a dental or surgical procedure done for diagnostic purposes and the case does not come under the jurisdiction of the medical examiner or coroner.When death occurs suddenly, unexpectedly, or in mysterious circumstances from apparently natural causes and the case does not come under the jurisdiction of the medical examiner or coroner.

The Medico-Legal or hospital autopsyWhen environmental or workplace hazards are suspected.When death occurs during or after childbirth.When there are concerns about a hereditary disease that might affect other members of the family.

The Medico-Legal or hospital autopsyWhen there are concerns about the possible spread of a contagious disease.When the cause of death could affect insurance settlements (policies that cover cancer or that grant double indemnity for accidental death).When death occurs in a hospital and the patient comes from a nursing home and the quality of care is questioned.

The Clinical or Pathological examiner autopsies ordered to determine 1. Cause of death.2. Manner of death.3. Time of death.4. Recovering, identifying and preserving evidence.5. Provide factual objective information for legal authorities.6. Separate deaths due to disease from deaths due to external causes.

Report to the medical examiner immediately

1. Victims of homicide.2. Victims of deaths in the workplace3. Motor vehicle drivers who have been involved in accidents.4. Pedestrians who have been involved in accidents.

5. Passengers who have been involved in accidents but who lack clear evidence of trauma.6. Victims of intra and perioperative accidental deaths.7. Epileptics.8. Possible victims of sudden infant death syndrome.

Report to the medical examiner immediately

9. Infants or children with evidence of bodily injury.10. Inmate fatalities in correctional facilities, nursing homes or medical institutions.11. Victims of trauma.12. Victims of non-traumatic, sudden unexpected deaths.Report to the medical examiner immediately

13. Victims of anorexia nervosa14. Multiple victims of coincidental unexplained death at on location.15. Victims of possible poisoning or overdose deaths.16. Any other case in which the pathologist holds a bona fide belief that the death is unexplained and or an autopsy is in the best interest of the public or that it is necessary for the proper administration of the statutory duties of the office of the coroner.Report to the medical examiner immediately

IF EVER IN DOUBT PLEASE CONTACT YOUR LOCAL MEDICAL EXAMINER.

Anatomical or academic autopsies Performed by students of anatomy for study purpose. This is usually possible when a person has given permission in advance of their death for their body to be donated to science.

Virtual or medical imaging autopsies are dubbed virtopsy, ignited interest in applying postmortem imaging to other forms of traumatic injury. Since 2004 the U.S. military has performed x-rays and CT or CAT scans (computerized axial tomography) on the bodies of every service member killed where the armed forces have exclusive jurisdiction, not just on battlefields abroad but on U.S. bases as well. Virtual or medical imaging autopsies It allows for identification of any foreign bodies present, such as projectiles. X-rays give you the edge detail of radio-opaque or metallic objects, so you can sort out what the object might be, and CT, because it is three-dimensional, shows you where the object is in the bodyVirtual or medical imaging autopsies In Egypt when a post mortem exam must be performed on a 2000 year pharaoh imaging is an adjunct to the traditional external and internal postmortem exam.

Work Practice ControlsHealth and safety issues associated with embalming are addressed by compliance with The Bloodborne Pathogen Rule.

The Bloodborne Pathogen Rule is administered by the United States Department of Labor through OSHA.

Work Practice ControlsThe embalmer and his/her assistant are professionally responsible for his /her own personal hygiene, health and safety because of the direct contact with the decedent. The use of universal precautions and personal protective equipment (PPE) should be provided by the employer and used by the embalmer and his/her assistant and is necessary for the preparation of all bodies.

Work Practice ControlsProper ventilation and air flow throughout the preparation room should be on at all times. According to OSHA: The Formaldehyde Standard Rule states that the air supply in the room should be exchanged at a minimum of 12 -20 times per hour for a single table room. You should keep in mind the size, shape and the contents within the room as well.Work Practice ControlsThe work practice controls when handling autopsied bodies should be that of extreme caution. Work Practice ControlsHere are some work practice controls you can use. Be aware of where cutting and sharp instruments are laid during preparation. a. put sharp instruments at the head of the table on the opposite side you are working b. put sharp instruments on the counter away from the working area.

work practice controls you can useCover broken or cut bones (e.g. ribs) prior to placement of embalmers hands into a body cavity. a. cover with hand towel b. cover with webril cotton prep towels c. autopsy rib covers

work practice controls you can useWash gloved hands or change gloves often during the embalming procedure.

Avoid use of high water pressure when water is used to flush blood and fluids from the embalming table.

work practice controls you can useContinuous aspiration of the cavities during arterial injection to remove drainage and excess arterial fluid. a. control blood drainage & blood contaminants, if death is a bloodborne infection, drainage can be a great risk to the embalmer.

work practice controls you can useClamp leaking arteries and small veins to avoid excessive embalming solution loss and improve solution distribution during arterial injection.Run table water continuously to dilute and carry away any blood or chemicals on the table surface.work practice controls you can usePack external orifices: rectum, esophagus, trachea, ears, and vagina.During embalming, the calvarium and the removed portions of the sternum can be soaked in a preservative solution in a closed container or sealed plastic bag.PreparationAs stated before most autopsies are classified as a partial or the complete autopsy. The hospital can be either partial or complete and the medical examiner is more than likely to be a complete autopsy. We can review the difference in both types.PreparationPartial autopsy:During these types of autopsies they are limited by the person giving permission. In most cases the immediate next of kin. The cavities which can be dissected during the autopsy are the cranial, thoracic, abdominal and the pelvic cavities. The partial autopsy looks at specifics such as mentioned previously.PreparationPartial autopsyThe abdominal and pelvic cavities are also called the abdominopelvic cavity region. When a partial autopsy will be performed the examiner will usually open one of these body cavities.Preparationcomplete autopsy: During these types of autopsies all of the above mentioned body cavities will be dissected. Also if the neck is in question such as an auto accident, a sharp fall, or shaken baby syndrome, the cervical spine will also be dissected for fractures. The partial autopsy looks at specifics such as mentioned previously.Preparationcomplete autopsy

The cervical spine is divided into two parts; . The upper cervical region (C1 and C2). C1 is termed the Atlas and C2 the Axis.The lower cervical region (C3 through C7). Preparationcomplete autopsyTo reach the cervical area the body is turned over from the lateral plane and placed on its frontal plane, (flip the body over). The Atlanta medical examiner and sometimes the GBI medical examiner will dissect the wrist area to see if the victim was holding a weapon during the occurrence of death.PreparationThe transverse carpal ligament and flexor tendons will be examined to see if the area is in a tense (locked) position.EmbalmingRaising vessels, hypodermic treatment, drying tissue, suturing When embalming a partial autopsy case it should not be too difficult for the embalmer. Depending on the organ that has been removed this can be a two point injection. The vessels can be ligated and the body can be embalmed from the position of the removed organ by injecting toward the upper extremities and toward the lower extremities. If this proves difficult a six point injection can be employed. Hypodermic treatment should be employed. EmbalmingWhen embalming a complete autopsy case a six point injection must be used. The vessels can be ligated and the body can be embalmed from the Lf. and Rt. Common carotid arteries injecting toward the head, Lf. and Rt. subclavian or axillary arteries injecting toward the arms and hand, and the Lf. and Rt. iliac or external femoral arteries injecting toward the legs and feet. Hypodermic treatment should be employed.EmbalmingMany embalmers have dropped the ball when hypodermically treating parts of the neck, across the scapula (shoulder blades) and small of the back, middle of the back, torso, and buttock regions. Some embalmers will embalm using one of the above mentioned methods but fail to use hypodermic treatments. What consist of proper hypodermic treatments? The body lies on the hard surface of the embalming table which is made of porcelain or stainless steel.EmbalmingHypodermic treatment of parts of the neck, across the scapula (shoulder blades) and small of the back, middle of the back, torso, and buttock regions should be hypodermically treated to ensure good fluid distribution of these areas. EmbalmingYou should pay close attention when hypodermically treating the lower back and the upper buttock regions, this area has a tendency to decay fast and have a tremendous odor due to the lack fluid distribution. It becomes evident as you move the body for dressing that this area has failed to be treated.

EmbalmingOn the inside of the body the ribs can be incised (between each intercostal space) with the scalpel from the point where the breast or sternum plate has been removed as far back as you can get to the spin. There will be some leakage in this area due to the hypodermic treatment. Some embalmers will allow the body to drain over night before continuing the process. EmbalmingAt this point you can further dry the tissue area with a towel or cotton. A cauterizing agent can be used to aid in the prevention of leakage in the cranium area once the facial tissue has been pulled over. The cauterizing agent should be placed on cotton and dabbed on the exposed tissue areas such as the neck and torso regions as well. EmbalmingYou can then place autopsy gel in the exposed cranium area and the inside of the neck and torso areas with a paint brush or saturate cotton and dab the exposed regions. This will further penetrate and preserve the tissue. EmbalmingDrying compound, hardening compound or a mixture of both can be used to further dry and preserve the tissue and prevent leakage. The calvarium and the breast or sternum plate should be treated using the same methods as just mentioned before being replaced inside the body area. Viscera the proper treatmentWhen the medico-legal or hospital autopsy has been performed, the organ that has been studied may or may not be returned.

If the autopsy has been performed at a hospital that is classified as a teaching institution you may or may not have the viscera returned. These institutions use the viscera as teaching aids for students. Viscera the proper treatmentThe clinical or pathological examiner autopsy, the viscera is returned with the decedent.

The anatomical or academic autopsies and the virtual or medical imaging autopsies we do not have to discuss because of the type of autopsy being performed.

Viscera the proper treatmentWe must keep in mind that each county and state has different protocols when performing autopsies.Viscera the proper treatmentWhat are the proper treatments of the viscera and the cavities of the body once the viscera have or have not been returned with the decedent?

We have to explore two different methods.Viscera the proper treatmentWhat to do if you want to replace the viscera within the body cavity. a. within the viscera bag. b. without the viscera bag.

Viscera the proper treatmentWhat to do if the viscera were not returned, or if you wish not to return the viscera to the body cavity. a. viscera placed in a fluid box within the casket.Viscera the proper treatment First method:

Lets look at replacing the viscera bag within the body cavity. Viscera the proper treatmentA method that was taught to me by the late Sgt. Willie Adams was to open the viscera bag and cut the large intestines to allow all air to escape. If you wish you can cut as much of the viscera as you can into smaller pieces and allow the cavity fluid to penetrate thoroughly. Manipulate the viscera bag into a cigar shape. The cigar shape along with incising the ribs (intercostal space) will ensure the viscera fits properly back into the cavity.

Viscera the proper treatmentFill a sink with hot water submerge the viscera bag within the hot water within the sink.

This will speed the reaction of the cavity fluid from a liquid to a gas and penetrate the viscera causing immediate tissue fixation. Viscera the proper treatmentOnce you are ready to replace the viscera bag you can aspirate the remaining liquid from the viscera bag, press all the air from the viscera bag. If you wish you can add drying and or hardening compounds within the viscera bag and replace the viscera bag within the cavity of the body. Once the viscera bag has been properly fitted to the cavity region of the autopsied body you can tie the viscera bag with ligature.

Viscera the proper treatmentIf wish not to drain the cavity fluid from the viscera bag that is ok as well, but the remaining air must be pushed from the viscera bag and properly tied with ligature. Some may wish to place small slits within the viscera bag to allow gas to escape, no more than two or three. If the bag leaks you have more than enough drying agents within the cavity area to control this problem. The breast or sternum plate can be replaced at this time. Viscera the proper treatmentIf the bag leaks you have more than enough drying agents within the cavity area to control this problem. The breast or sternum plate can be replaced at this time.Viscera the proper treatmentSecond method:

Lets look at replacing the viscera without the viscera bag back into the body cavity.

Viscera the proper treatmentOpen the bag and cut the large intestines to allow all air to escape. If you wish you can cut as much of the viscera as you can into smaller pieces and allow the cavity fluid to penetrate thoroughly. Fill a sink with hot water submerge the bag within the hot water within the sink. This will speed the reaction of the cavity fluid from a liquid to a gas and penetrate the viscera causing immediate tissue fixation.

Viscera the proper treatmentOnce you are ready to replace viscera you can aspirate the remaining liquid from the viscera bag.Press all the air from the viscera bag, add drying and or hardening compounds within the viscera bag.Shake the viscera bag making sure that all the viscera have been coated with the drying and or hardening compounds.Viscera the proper treatmentPick up each piece ensuring that the drying and/or hardening compounds have coated properly.Fit the viscera within the body cavity. You may wish to add more drying and or hardening compounds.

What to do if the viscera were not returnedReading what I could find online a few older embalming pamphlets and some of the older embalming text books, the body cavity could be refilled by using sawdust mixed with powdered lime, charcoal and plaster of paris. What to do if the viscera were not returnedThe sawdust would act an absorbent and as filler, the lime and charcoal would control odor and the plaster of paris would act as a drying agent and harden the tissue.They did use white packing paper which is like a newspaper without the text.

What to do if the viscera were not returnedWhat to do if the viscera were not returnedWhat to do if the viscera were not returnedWhat to do if the viscera were not returnedWhat to do if the viscera were not returnedTalking to the veterans of funeral service and the text books and the methods they employed, was sawdust mixed with plaster of paris, drying and or hardening compounds, and saturated cotton with cavity fluid placed over the ribs and within the bottom (back) of the cavity. What to do if the viscera were not returnedTo fill the cavity, they used white linen sheets, or wadded up newspaper. The paper was placed within the cavity as the body was being sutured. The paper acts as an absorbent and filler for the body cavity. What to do if the viscera were not returnedWhat to do if the viscera were not returnedWhat to do if the viscera were not returnedWhat to do if the viscera were not returnedUsing newspaper was widely used by all embalmers and it is still being used today. Because it is an older method some newer embalmers as well as outside sources feel that this method should be retired. In the days before the computer and the smart phone every business or house hold received a newspaper. In some areas there were two papers, a morning and an evening paper delivered.

What to do if the viscera were not returnedThe newer text books rely on using autopsy gels, drying and or hardening compounds to dry, preserve and deodorize the tissue while using cotton, or clean white linen sheets to fill the body cavity. At The Cincinnati School of Mortuary Science, we were taught that packing paper was ok but not to use newspaper. If the paper had been printed on then it was considered trash and should not be used even to fill out the casketWhat to do if the viscera were not returnedYou can use what is called waste cotton which is unbleached course cotton used in making furniture, beds or some casket companies use this for padding. It is much cheaper than bleached process cotton and can also be used for padding a casket or the decedent. What to do if the viscera were not returnedIt comes in a very large bale that will last much longer than processed cotton if trying to fill the body cavity or padding the decedent.

You cannot use waste cotton like bleached cotton; you cannot saturate waste cotton and use it such as a cavity pack. Disposition of the visceraWhat to do if you wish not to return the viscera to the body cavity.Open the viscera bag and cut the large intestines to allow all air to escape. If you wish you can cut as much of the viscera as you can into smaller pieces and allow the cavity fluid to penetrate thoroughly. Disposition of the visceraFill a sink with hot water submerge the viscera bag within the hot water within the sink. This will speed the reaction of the cavity fluid from a liquid to a gas and penetrate the viscera causing immediate tissue fixation. Take an empty fluid box line the box with another plastic bag place some drying and or hardening compounds within this bag. Remove the viscera bag from the water and dry the bag with a towel. Disposition of the visceraYou can aspirate the remaining liquid from the viscera bag, press all the air from the viscera bag, if you wish you can add drying and or hardening compounds within the viscera bag and place the viscera bag within the bag in the box.Press all air from the bag and use ligature to tie the viscera bag and tie the second bag. Tape the box closed, and place this box within another plastic bag.Disposition of the visceraRemove the casket bedding and spread the springs apart at the foot end of the casket. Be careful not to cut yourself or tear the plastic bag when spreading the springs apart. Place the box under the springs replace the casket bedding.

SuturingWe can begin to suture the cranium. The cranial cavity is filled with drying and or hardening compounds and packed with bleached cotton to absorb any leakage that may occur. The calvarium can be secured in many ways. You should choose what is best comfortable for you. SuturingStart the suture from the viewing side and continue to the non-viewing side and secure.Or start from the viewing side and suture over half the distance to the non-viewing side.

SuturingNext start second suture on the non-viewing side and continue over half the distance to the viewing side. Pull and tie both ends of the ligature together and the puckle will be in the pillow giving the two sutured halfs a nice tight appearance.

SuturingAt this time we can begin to suture the body. The neck area can be replaced with saturated cotton of autopsy gel or cavity fluid. I have also used a piece of card board rolled up and placed within the neck area. If you dont roll the cardboard to tight it makes the inside of the neck perfectly. You can bring the Y incision together with tissue gathering forceps or use ligature to hold the Y incision in place.SuturingI personally like to start at the middle of the Y incision and work my way down to the pelvic region. This will allow me to continue to shape the contour of the viscera bag within the cavity region as I stich closer to the pelvic region. Next I usually start at the outer edge of one side of the Y incision (shoulder area) and work my way back to the middle of the Y incision.SuturingIf you start at the outer edge of the Y incision, this will allow you to make a pocket and place incision sealer or mortuary putty within the incision as you work your way back to the middle of the Y incision. This method will help control any leakage that may occur. I then repeat this process on the opposite side of the Y incision and work back to the middle of the Y incision repeating the same previous step. SuturingWe have to look at both a child and an adult autopsy case. A new born up to at least 5 years. The viscera sometimes will not fit properly in the thoracic and pelvic cavities properly or the mother may want to hold the child. You can double bag the viscera and place the viscera bag under the casket bedding. Suturing6 years to 12 years You can use either method leaving the viscera out of the cavity and placing the viscera under the casket bedding or placing the viscera in the cavity area and following the above steps. 13 years to adult The viscera should be replaced but you can use either method mentioned above.Viscera disposition of the viscera.When the viscera are returned with the decedent, the viscera should remain with the decedent at all times until proper disposition. The viscera should never be left in the embalming room while the visitation or funeral service is being performed. Viscera disposition of the visceraWhen the viscera have been properly treated, there should be no odor and the viscera should remain with the body at all times using methods that were previously mentioned. There should be no cross contaminating of human remains such as putting the viscera with another decedent for the process of cremation. Viscera disposition of the visceraThere should be no co-mingling of human remains such as putting the viscera with another decedent for the process of cremation.Viscera disposition of the visceraStericycle will start to check the biohazard boxes periodically that come from funeral homes for pace makers and human remains such as viscera. Pace makers should be properly disposed of within a small hazardous box designed for the disposal of radioactive materials. If any such items are found in the biohazard box upon inspection the funeral home will be brought up on charges.

Bibliography

1. Strasser, Russell S. (2008). "Autopsies". In Ayn Embar-seddon, Allan D. Pass (eds.). Forensic Science. Salem Press. p. 95. ISBN 978-1-58765-423-7.2. Roberts, I. S.; Benamore, R. E.; Benbow, E. W.; Lee, S. H.; Harris, J. N.; Jackson, A.; Mallett, S.; Patankar, T.; Peebles, C.; Roobottom, C.; Traill, Z. C. (2012). "Post-mortem imaging as an alternative to autopsy in the diagnosis of adult deaths: A validation study". The Lancet 379 (9811): 136142. doi:10.1016/S0140-6736(11)61483-9. PMC 3262166. PMID 22112684.

3. Robert Mayer, fifth edition, 2012. Embalming History, Theory and Practice. Pages 327-344.

Bibliography4. Stericycle beginnings in 1989. Focused on helping businesses protect people and brands, promote health, and safeguard the environment. Also offers specialized waste disposal services to healthcare facilities and other businesses (mortuaries), such as: Pharmaceutical Waste DisposalHazardous Waste ManagementSustainability Services

Bibliography5. Occupational Safety and Health. 1910.1200 Hazard Communication (standards and nterpretations)6. Dr. Hans J. Peters, New York Times, July 21, 1998. The College of American Pathologists 7. Steve Parker, 2012. The Human Body: Complete illustrated Guide to its Structure, Function, Disorders and Anatomy. DK Publishing pages 5465. ISBN 978-5-0010-0705-0Bibliography8. Edward Mazuchowski, chief deputy medical examiner in the Armed Forces Medical Examiner System.9. Schafer, Elizabeth D. (2008). "Ancient science and forensics". In Ayn Embar-seddon, Allan D. Pass (eds.). Forensic Science. Salem Press. p.43. ISBN978-1-58765-423-7.10. Howard Eckels S. (1900). Derma surgery: with complete catalogue of embalmers' supplies

Full Autopsy-Two PT injection

Full Autopsy- 6 PT injection