Embalming History, Theory, and Practice Chapter 15 PDF

CHAPTER 15 Treatments after Arterial Injection CHAPTER OVERVIEW Post-embalming Treatments Removal of Medical Devices Types of Suture Methods Plastic Garments Terminal Disinfection and Embalmer Hygiene Periodic Monitoring Until Final Disposition POST-EMBALMING TREATMENTS Post-embalming treatments are...

CHAPTER 15 Treatments after Arterial Injection CHAPTER OVERVIEW Post-embalming Treatments Removal of Medical Devices Types of Suture Methods Plastic Garments Terminal Disinfection and Embalmer Hygiene Periodic Monitoring Until Final Disposition POST-EMBALMING TREATMENTS Post-embalming treatments are routinely carried out after completion of arterial and cavity embalming. Numerous variables, including preferences of the embalmer, influence the order in which each treatment is performed. 1. Supplemental preservative and corrective treatments. 2. Adjustments to feature setting. 3. Closure of incisions. 4. Packing of orifices. 5. Removal of invasive medical devices. 6. Final bathing and inspection of all bodily areas. 7. Application of adhesives to incisions. 8. Applying plastic garments. 9. Terminal disinfection of instruments and preparation room surfaces. 10. Removal and disposal of personal protective equipment (PPE). 11. Handwashing and related personal hygiene. 12. Preparation of documents. SUPPLEMENTAL EMBALMING Insufficient preservation can exist following arterial embalming when solution does not adequately distribute within the vascular system. Additional arteries are raised and injected closest to the unaffected areas. Unembalmed areas that remain after these attempts will be treated by supplemental embalming methods. There are two supplemental methods of embalming: surface embalming and hypodermic embalming. Surface Embalming Surface embalming is the application of an embalming chemical directly to the surface of the tissues. Surface embalming chemicals and compresses (packs) are applied to both external and internal body surfaces. External compresses are applied directly to the exposed skin surfaces. Internal surface compresses are called inlays. Inlays are applied to the unexposed surface tissues of the buccal cavity (inside of the mouth), beneath the eyelids, inside the nasal cavity, beneath the autopsied scalp, and to the interior walls of the autopsied trunk. There are numerous other applications for inlays. Applications to intact skin areas are made anywhere on the body. Areas of broken skin such as abrasions, skin slip, burned tissues, and lesions respond favorably to surface embalming. Following treatment, cover chemicals and compresses with plastic sheeting to reduce fumes and to prevent the chemical from evaporating. Accessory chemicals formulated for surface embalming include liquids (phenol cautery agents, cavity fluid), preservative formalin creams and gels (autopsy gel), preservative powders, and drying and hardening compounds. Accessory chemicals are specifically formulated to preserve, cauterize, dry, deodorize, and bleach tissues on contact. Many of these formulations contain phenol. For treatment of severe conditions, products may need longer application times. Where a phenol compress is removed, the area can be rinsed with alcohol to stop further bleaching and drying action. Creams and gels are applied directly to the skin using a widebristled brush or poured onto cotton and applied as a surface pack (compress). Gels are available in two choices: low viscosity (semiliquid) or in high viscosity form (gelatinous). Creams and gels are designed to rapidly penetrate the tissues. They can remain in place on nonviewable areas, covered with plastic sheeting or a plastic garment. Arterial fluid is not recommended as a surface embalming chemical; cosmetic dyes in the fluid can stain the skin. The penetrating action of arterial fluids is slower compared to cavity fluid and accessory surface chemicals. An arterial fluid designed to penetrate rapidly would not distribute within the vascular system. After the surface compress is removed, rinse and dry the area before cosmetic application. Hypodermic Embalming Hypodermic embalming is the subcuticular injection of preservative chemicals using a hypodermic needle and syringe or a small-gauge trocar. This method is used to treat both small localized body areas and larger areas, such as the trunk walls of the autopsied body, a limb that did not receive sufficient arterial fluid, or an area that cannot be arterially injected. Hypodermic needles are available in varying gauges and lengths. Smaller bores needles (18–22 gauge) are ideal for tissues of the face and hands; large-bore needles (10–16 gauge) are used for greater surface areas. Larger needle entry sites may be closed using a trocar button; smaller sites can easily be sealed with glue. An infant trocar or hypovalve trocar can be connected to the centrifugal embalming machine for the injection of large body areas. The arterial solution used for arterial injection can be used for hypodermic injection. It is recommended that it be strengthened with a high-index arterial fluid. Arterial solution should only be used on areas that will not be viewed, as the dye in the fluid can blotch the skin. Cavity fluid as well as specially designed accessory embalming chemicals may be used for hypodermic embalming. Phenol solutions should be reserved for localized treatments of discolored areas or tissues when bleaching of tissues is necessary. The phenol solutions would not be used for routine supplemental hypodermic embalming. Be advised that cavity fluids and fluids containing phenol may void the manufacturer’s warranty when used in the embalming machine. Treatments for Visible Areas Well-preserved tissues will not dehydrate at the rate of poorly embalmed tissues. Application of glue to the eyelids and lips reduces the effects of dehydration; the marginal tissue membranes of both lids and lips are moist and will rapidly dry, shrink, and discolor. Visible areas treated by surface inlays or compresses can be coated with a massage cream or spray after the chemical is removed. The creams and sprays may also provide a good base for cosmetic application. Mouth, Lips Cotton can be placed over the teeth or dentures and moistened with cavity fluid. Use a hypodermic needle and syringe to apply a few drops of fluid. The lips can then be glued; the preservative works from inside the oral cavity to preserve the tissues of the lips and mouth. Cosmetic treatment can be immediate using this method of preservation. Eyelids Insert a small amount of cotton independently or in combination with an eye cap. Draw a small amount of cavity chemical into the hypodermic syringe. Moisten the cotton with a few drops (Fig. 15–1). Close the eyes and seal the lids with an adhesive. Figure 15–1. Cotton placed beneath eyelids and moistened with a few drops of cavity fluid. In facial areas, where hypodermic needles would be used, most of the injections can be made from inside the mouth. In this manner, leakage will not exit onto the face. Unlike tissue builder, these chemicals have a tendency to seep from the point of puncture. In the autopsied body, large portions of the face can be reached through scalp incisions. The hands can be injected from either the palmar or dorsal surface. The needle is directed between the fingers (Fig. 15–2). The thumb and fingers are injected directly by guiding the needle toward the tip of the digit (Fig. 15–3). Super adhesive can be applied to the needle puncture after injection to prevent leakage from the site. Figure 15–2. Hypodermic injection of the hand to bleach blood discolorations. Figure 15–3. Hypodermic injection of the thumb (and fingertips) to create natural contour. The nose can be treated hypodermically by inserting the needle inside the mouth. The ear can be reached by hypodermic injection from behind the ear. For larger areas, such as the arm and leg, the infant or hypovalve trocar can be inserted into the area of the cubital fossa of the arm to reach the arm and forearm. If the elbow area contains edema, the trocar can also be entered from the upper pectoral region to reach the distended area. The leg can be treated by inserting a small-gauge trocar just inferior or superior to the knee. From this point, both the thigh and lower leg can be reached (Fig. 15–4). Trunk walls, hip, and buttock can be reached by inserting a trocar into the center of the lateral trunk wall. Figure 15–4. Treatment of the lower leg using a hypodermic trocar. Nose Cotton saturated with preservative fluid can be inserted into the nostrils. Later, push the cotton further into the nasal cavity so that it will not be noticeable. A small-gauge hypodermic needle can be used to inject a preservative solution from inside the nostrils into various areas of the nose. If hypodermic treatment is used, expect some leakage from the injection sites. Cotton can be placed within the nostrils to absorb residual leakage and later removed. The bridge of the nose, nasal septum (columella nasi), tip, and wings often need contouring for natural appearance. Careful handling and directing of the needle will prevent injury to the embalmer during hypodermic injection. Treatments for Nonvisible Areas For areas that will not be seen, such as the legs or feet, supplemental treatments can be used to enhance preservation. Surface embalming powders have been used for many years. Diapers can be used to contain the powder, or the powder can be placed in plastic garments such as stockings, coveralls, or pants after the garments are in position. Powders can also be used to treat the interior walls of the abdomen and thorax in the autopsied body. Powders are not as effective as gels or liquids. Read the label to be certain the powder is a preservative and not just a deodorant or absorbent. Treatments for Larger Areas Certain conditions, such as arteriosclerosis, gangrene, and edema, require additional injection of the legs. A combination of supplemental embalming methods (hypodermic and surface) can be used. If arterial treatment has been unsuccessful, the legs can be injected hypodermically. The solution injected can be undiluted arterial or cavity chemical. The legs can also be painted with autopsy gels and embalming powder can be placed into the plastic stockings. In the trunk area, hypodermic injection can be used when the tissues have received insufficient arterial fluid. Coveralls, pants, or a Capri garment can be used and embalming powder or autopsy gel painted over the areas being treated. When edema is a problem in the elbow area, hypodermic treatment can be used (inject from the upper arm), paint with autopsy gel and wrap with gauze. A plastic sleeve can then be placed over the treated area. In nonviewable areas where the infant trocar or hypovalve trocar has been used, the punctures can be sealed with a trocar button. When machine injection and a trocar are used, phenol products should be avoided. Phenol can be damaging to injection machines. When injection is completed, the embalming machine must be thoroughly flushed and cleaned; clear ammonia run-through the machine will help to eliminate formaldehyde residue. CLOSURE OF INCISIONS Two methods are commonly used to close incisions, sutures and super adhesive glue. Best practices prior to incision closure: 1. Do not suture until after cavity aspiration; aspiration relieves pressure on the vascular system and helps to prevent leakage. 2. Be certain all vessels are securely tied. This prevents any further leakage. 3. If there is edema in the surrounding tissues, force as much liquid out of the incision as possible. 4. Dry the incision. 5. Cotton saturated with a cautery solution can be placed into the incision. This compress can remain within the incision (Fig. 15–5). The addition of incision seal powder, will also help to prevent leakage. Figure 15–5. Cotton saturated with cautery solution prior to suturing the incision. 6. Make several sutures before adding the incision seal powder to the incision. Pull upward on the suture thread to create a “pocket”; direct the powder into the pocket. 7. After suturing, apply a liquid or spray sealant to the area to prevent leakage. Suturing Cotton or Linen Thread Linen thread is stronger than cotton thread and is recommended for autopsy, long bone donors, and vessel incision sutures. For restorative sutures, which are located on visible areas, dental floss is an excellent material to use. A 3/8-inch Circle Needle The 3/8-inch circle needle is used for restorative sutures and to suture incisions made to raise vessels. Double-Curved (S-Curve) Postmortem Needle The double-curved autopsy needle is easy to grip with the gloved hand. It is used to close autopsy incisions, long-bone donor incisions, surgical incisions, and incisions made to raise vessels. Postmortem needles come in a variety of sizes and shapes: halfand double-curved, circle, and Loopuypt styles. Some have a patented “spring-eye” for easy threading of the needle. Regardless of the size or the shape of the needle, it is most important to keep it sharp. Suturing can be very dangerous if the needles are dull, as extra pressure must be applied. In doing so, the embalmer increases the chance of the needle breaking or piercing her or his skin. A sharp needle makes suturing much easier, safer, and faster. To tighten the suture, pull on the thread and not on the needle. Pulling on the needle weakens the suture thread where it passes through the eye of the needle, and breakage can occur. The embalmer can suture using single- or double-stranded thread. This depends on the strength of the suture thread or on the type of suture. It is wise to double the thread when cotton thread or three- or four-twist linen thread is used. Single-strand suture thread works best with five- and six-twist linen thread (dental floss). Direction of Suturing To make suturing more efficient, follow these directions for the various sutures. Common carotid artery. If using the parallel incision, suture from the inferior portion of the incision superiorly. Suture from the medial portion of the incision laterally if using a supraclavicular incision. Axillary artery. Suture from the medial area of the incision laterally (with the arm abducted). Brachial artery. Suture from the medial portion of the incision laterally with the arm abducted). Radial and ulnar arteries. Suture from the distal portion of the incision medially. Femoral artery. Suture from the inferior portion of the incision superiorly. Autopsies (trunk standard “Y” incision). Use bridge sutures to align the skin into position. Begin the trunk suturing at the pubic symphysis and suture superiorly. Popliteal artery. Begin the suture at the inferior (or distal) portion of the incision and suture superiorly. Anterior and posterior tibial arteries. Begin the sutures distally and suture superiorly. Sutures Bridge, or Individual Sutures Bridge sutures temporarily align tissue margins and secure them in position until permanent sutures replace them (Fig. 15–6). Numerous bridge sutures are placed to align the tissue flaps of the Y-incision created during autopsy. Figure 15–6. Bridge, or individual suture. Baseball Suture The baseball is the most commonly used suture to close incisions (Fig. 15–7). It is considered the most secure and leakproof. In addition to the closure of incisions at the injection site, it is suited for closure of lengthy incisions, as in autopsy, surgery, and long-bone donation. To make this stitch, pass a suture needle and thread from beneath the incision up through the integument, and cross the needle from side to side with each stitch (Fig. 15–8). The resulting lacing pattern is similar to the stitching on a baseball. As each stitch is pulled tightly, the tissues adjacent to the incision pucker and create a visible ridge on the skin surface (Fig. 15–9). Figure 15–7. Baseball suture. Figure 15–8. Baseball suture. The suture needle is directed side to side in a lacing pattern. Figure 15–9. Tightened baseball sutures create a visible ridge. When the baseball suture is used for the closure of lengthy incisions, the thread can be knotted, or locked down every few inches. This prevents the thread from unraveling should it break. If the thread does break, it will not be necessary to start the entire suture over again. To lock the suture, pass the needle through both sides of the incision and tie a knot as though the suture were completed. Do not cut the ligature; use the same thread to continue suturing. Locking down the suture will also relieve tension from the thread, minimizing fatigue to the embalmer’s hand during suturing. Interlocking (Lock) Suture The interlocking suture continues throughout the closure; unlike the occasional lock down practice above. A tight, leak-proof closure is created. The disadvantage is the visible ridge on the surface of the incision. To begin, direct the needle through both epithelial margins of the incision. Keep the thread tight with the hand not holding the needle. Lock the stitch by looping the thread and passing the needle through the loop. Pull the thread tight. Insert the needle on the same side of the incision each time the process is repeated until the incision is closed. Single Intradermal (Hidden) Suture The single intradermal suture is made entirely within the dermal layer, traversing the needle side to side within the incision. The needle does not pass through the epidermal tissues, the thread is hidden from view (Fig. 15–10). To begin the closure, insert the needle deep into the dermal tissues at one end of the incision. Make a knot in the thread a short distance from the end and pull the knot to the position of the needle entry in the integument. Direct the needle in a backand-forth pattern from one side of the incision to the other. Align the margins of the incision as the thread is drawn to prevent gaps and tissue misalignment. To complete the closure, direct the needle through the integument as far as possible from the end of the incision. Draw the margins of the incision together by pulling on the free end of the thread. Puckering will result if the thread is pulled too tightly. Pull upward on the thread and cut the thread at the tissue surface; the excess thread disappears into the incision. Figure 15–10. Single intradermal, or Hidden suture. Double Intradermal Suture The double suture is knotted at each end, creating greater holding strength than the single intradermal. This is also a dermal layer suture. The same thread is used for two needles; one needle is threaded at each end. One of the needles is directed through the tissues of one side of the incision; the other needle on the opposite side. Maintain parallel stitches that resemble the lacing pattern of a shoe. Continue the process until the incision is completely sutured. After drawing the margins tight, knot the two ends together. Relieve any tissue puckering by smoothing the incision with digital pressure. To end the suture, pass both threads through the eye of one needle. Insert the needle beneath the skin at the end of the incision and pass it approximately one-half inch. Pull upward and cut the thread at the tissue surface; excess thread disappears into the incision. Inversion, or Worm Suture The inversion suture gathers and turns under excess tissues (Fig. 15–11). Inverted tissues create a flat closure; a visible ridge on the skin surface is avoided. The incision is easily concealed. After completion, the knot can be pulled into the incision and the excess thread cut closely to the surface. No thread is visible. The lacing pattern is similar to the single intradermal. Stitches are made on the surface only; the needle passes back-and-forth overtop the skin surface rather than into the dermal tissues. Each stitch is made parallel and close to the margin of the incision (Fig. 15–12). Stitches that are uniform in length and drawn moderately tight produce an optimal closure. The inversion is ideal for suturing the cranial autopsy incision and the smaller incisions used for arterial injection (Fig. 15– 13). The inversion suture is not drawn as tightly as the baseball and may not be suitable for trunk autopsy incisions. Figure 15–11. Inversion, or Worm suture. Figure 15–12. Inversion or Worm Suture. The needle runs parallel to the incision. Figure 15–13. Completed inversion suture for the cranial autopsy incision. Continuous, or Whip Suture The continuous suture is used to temporarily close lengthy incisions (Fig. 15–14). Disadvantages include a visible tissue ridge, visible suture thread, and leakage potential. The exposed thread can draw, or wick body fluids; the thread will remain wet. Surface glues may not adhere and clothing can be soiled. Routinely, the whip stitch is used by autopsy and organ procurement technicians to temporarily restore the body cavities for transfer to the funeral home. To make this stitch, direct the needle through both epithelial margins of the incision. Reverse direction of the needle and pass overtop the skin surface, back to initial needle entry site. Place the next stitch one-half to one full inch beyond the previous stitch. Repeat the process until the closure is complete. Figure 15–14. Continuous, or Whip suture. Concealing the Suture Thread and the Knot The final length of thread and the knot can be completely hidden when suturing is complete. This practice prevents any exposed thread from wicking moisture from the incision and remaining wet. The incision can be easily concealed when the clothing provided does not hide the incision. Application of cosmetics and restorative waxes can be used for concealing. At the completion of suturing, place a knot in the thread. Move the knot as close as possible to the surface of the skin. Do not cut the thread. Place the needle beside and directly against the knot. Drive the needle into the incision 2 or 3 inches away from the knot and exit the incision. Pull the thread taut, with a quick snap on the thread the knot will disappear. Excessive force will pull the knot too deeply. The objective is to hide the knot just below the epithelium yet keep it embedded in the dermal tissues. Cut the tail of the thread close to the skin surface and it will disappear into the incision. Both thread and knot are no longer visible. Apply adhesive glue to the exit hole. See Fig. 15-15A–D. Super Adhesive Glue and Bonding Agents Super adhesive glues and bonding agents can be used for some closures in place of sutures. A variety of types are available. Some are suitable for bonding in the presence of moisture. These adhesives are a good choice for sealing jagged tissues that cannot be sutured. Routinely, glues are applied to sutured incisions to prevent leakage. The tip of the applicator can be used to apply the glue directly, or glue can be applied first to an instrument for application. Clean the instrument or applicator tip after use to prevent buildup. REMOVAL OF INVASIVE MEDICAL DEVICES Pacemakers and Defibrillators Devices containing batteries must be removed when cremation is the method of final disposition; batteries create explosion and injury hazards during the cremation process. Remove the device through a small semilunar incision. Best practice is to cut wire leads independently with surgical scissors. A strong magnet can interrupt the device mode but will not turn off the device. Close the incision by suturing or application of a bonding agent or super adhesive glue. Colostomy A colostomy is the opening of the colon through the abdominal wall to the skin surface. The stoma is the exposed portion of the bowel. Remove and disinfect the colostomy collecting bag before disposal in a biohazard waste container. Topically treat the area with a compress of cavity fluid or a phenol solution. The stoma can be reinserted in the body cavity using firm pressure. Either of the purse-string suture (Fig. 15–16) or the reverse suture, also called an N-suture or Z-suture (Fig. 15–17) can effectively close the colostomy. Seal the closure with glue to prevent leakage. Figure 15–15 A. Needle is placed beside knot and directed into the incision. B. Suture thread is pulled through the incision. C. Knot is hidden. Only tail of the thread is exposed. D. Thread is cut close to the surface of the skin. Thread and knot are no longer visible. Figure 15–16. Purse-string suture. Figure 15–17. Reverse suture, also called the N-suture or Z-suture. Surgical Drains Surgical drains are placed postsurgically to prevent the accumulation of blood, pus, and infected fluids; to prevent accumulation of air; and to identify the type of fluid leakage. Remove surgical drains and close the openings using a purse-string suture. TREATMENT OF DISCOLORATIONS AND ULCERATIONS Additional treatments for discolorations and ulcerations continue after embalming. Discolorations may be bleached at this time in preparation for cosmetic and restorative applications. Ulcerations may be treated a second time to ensure sanitation before dressing. TREATMENT OF PURGE After arterial and cavity embalming, the possibility of purge exists from any of the orifices. Tightly packing the throat prior to mouth closure and arterial injection can decrease any purge from the mouth. Packing the nose prior to arterial injection can create a blood or fluid purge from the nostrils during arterial injection. The mouth, nose, and anal orifice can also be packed after embalming is completed. This allows the evacuation of purges and fecal matter during the embalming and the cavity treatment. When anal purge is present after embalming, force as much purge as possible from the rectum by firmly pressing on the lower abdominal area. Pack the rectum using cotton saturated with cavity fluid, autopsy gel, or a phenol solution. Dry packing should be inserted into the anal orifice after the moistened cotton. Leave a portion of the dry cotton so that it can be seen. This will help to fully block the anal orifice. An AV plug device may also be used to seal the orifice. When purge is present from the mouth or nose immediately following arterial injection and cavity treatment, it may be necessary to reaspirate and reinject cavity fluid. Clean out the orifices and be certain they are tightly packed with plenty of dry cotton or cotton webbing. If possible, repack the throat area. TREATMENT OF DISTENSION Visible areas such as the face, neck, and hands that are distended may need to be reduced for viewing of the body. These treatments can be carried out during the post-embalming period. Some swellings, such as edema, can be treated by specific arterial solutions during arterial injection. It is necessary to know the cause of the distension to perform the best corrective treatment. Swellings present before arterial injection should be documented on the Embalming and Decedent Care Report. Examples of such conditions include edema, tumors, swellings caused by trauma, distension from gases of decomposition in the tissues or cavities, tissue gas produced by Clostridium perfringens, distension caused by allergic reactions, distension brought about by the use of steroid drugs, and gases in the tissues from subcutaneous emphysema. Distension of facial tissues, the neck, or glandular tissues of the face or the tissues surrounding the eye orbit during embalming of the body can be caused by an excessive amount of arterial solution in these tissues. Some of the causes of this swelling are very rapid injection of solution, use of too much injection pressure, poor drainage from these areas, breakdown of the capillaries due to trauma or decomposition, excessive massage, and use of arterial solutions that are too weak. It is essential during embalming of the body that the embalmer is alert to any tissue distension. Injection should be immediately stopped and the situation evaluated and remedied. In pitting edema, excess moisture is present in the tissue spaces. In solid edema, the excess moisture is within the cells. Pitting edema can be moved by mechanical aids such as gravitation, massage, channeling of the area, and application of pressure using a pneumatic collar, weights, elastic bandage, water collar, or digital pressure to move the moisture to another area. Elevation of the head and firm digital pressure slowly drain pitting edema from the facial tissues. During cavity aspiration, the trocar can be used to channel the neck, which may allow some of the edema to drain from the facial tissues into the thorax. Edema of the eyelids can be treated in several ways: (1) weighted surface compresses, (2) cavity fluid on cotton under the eyelids, during and after injection, (3) hypodermic injection of phenol compound or cavity fluid after embalming, and (4) by use of a tissue reducing spatula after embalming. After preservation of the lids is accomplished, channels can be made under the skin from within the mouth or temple area. Carefully apply external pressure to the distended tissues and massage as much of the edema from the tissues as possible. A side effect of removing edema from the facial tissues or hands is that the skin may become very wrinkled. Tissue preservation must always be the primary concern. The tissue-reducing spatula may also be used to remove wrinkling from the eyelids. Subcutaneous emphysema is air trapped in the subcutaneous tissues. Cardiopulmonary resuscitation, a traumatic event, or surgical procedure can puncture the lung and allow gas to escape into the subcutaneous tissues. As the individual struggles to breathe, more air is forced into the body tissues. Gases can easily be detected after death by palpating the tissues. The term crepitation is used to describe the spongy feel of the gas as it moves through the tissues when they are pushed upon. Arterial injection and blood drainage may remove a small portion of the gas, but gas that is trapped in the facial tissues must be removed by channeling. Channeling can be done post-embalming. A scalpel or hypodermic needle is used to channel the affected facial tissues from inside the mouth. Once the channels are made, the gas can be manually squeezed from the tissues. The lips can be lanced to release trapped gases. If the eyes are affected, the lids can be everted and the underside of the lids incised with a suture or hypodermic needle. Cotton can be used to close the eyes; it will also absorb any leakage. Subcutaneous emphysema can be differentiated from true tissue gas. True tissue gas has a very distinct foul odor that worsens progressively and is caused by an anaerobic bacterium. Blebbing and skin-slip develop with true tissue gas. (See Chapter 24 for treatments of true tissue gas.) RESETTING AND GLUING THE FEATURES The features can be corrected after embalming. Additional cotton or mastic compound can be inserted to fill out sunken and emaciated cheeks. If the cotton that was originally used to set the features becomes moist during the embalming, as a result of contact with purge or blood and fluid from the suture or needle injector used for mouth closure, it should be replaced with dry cotton. The dentures are not always available at the beginning of the embalming. The mouth can be reopened and the dentures inserted afterward. These procedures are more difficult when the tissues are firm and less pliable. Eyes can be closed or reset after arterial injection. (Refer to Chapter 18 for post-embalming procedures after eye enucleation.) After the features have been properly aligned, the features can be secured with glue. Adhesive applied to the lips and eyelids helps to avoid separation caused by dehydration. The area where the adhesive is to be applied should first be cleaned with a solvent. The skin of the lips and margins of the eyelids should be clean, dry, and free of moisture or oils. Super adhesive glue works very well for securing the eyelids. It ensures good closure of the inner canthus, which dries quickly and darkens. Apply glue to the mucous membranes behind the weather line. If the body was transferred from another funeral establishment, the lips may separate during travel or during a flight. During the delay, the tissues have additional time to become very firm. In such cases, the lips can be stretched or exercised with the blunt handle of an aneurysm needle or a pair of forceps. If the eyelids separate, they may also have to be exercised or stretched to obtain closure. Super adhesive glue is more effective in securing the mouth and eyes when the tissues are very firm. FINAL INSPECTION, BATHING, AND DRYING After final inspection of the entire body, shampoo the hair and bathe all areas to remove dried blood and chemical odors. Thorough drying eliminates the potential for mold growth on the skin surface, especially in warm climates. Apply a massage cream or spray to face and hands and cover the body completely with a full sheet. A layer of plastic sheeting to cover the face will decrease surface evaporation. PLASTIC GARMENTS Prior to dressing, protective plastic garments can be placed on the body to contain any minor leakage and odors (Fig. 15–18). Adult incontinence garments may also be used if minor leakage is anticipated. Figure 15–18. Plastic pants. Be certain the body is thoroughly dried before using a plastic garment. Pants or coveralls can be placed on the trunk when the leakage from the orifices, ulcerations, or traumatic injuries is present. The capri garment is ideal for coverage of the full lower extremities, from the hips to the feet. Plastic stockings are used after surface treatment of the legs. Plastic sleeves may be applied over broken skin at the elbows or on the arms. Place embalming and absorbent powders into the garment to control leakage, mold growth, and odor. If general edema, tissue decomposition, or extensive burns are present, a unionall may be necessary to protect clothing and casket fabric from soiling. The unionall is a plastic garment which covers the entire body, except for the neck and head. Plastic garments are available up in a variety of sizes. Best practice is to use a garment slightly larger than necessary. Terminal Disinfection Terminal disinfection practices are carried out after the embalming process to comprehensively clean all of the preparation room surfaces. The floors, countertops, cabinets and drawer handles, mortuary equipment, and any other soiled surfaces are included. Instruments are cleaned, placed into cold sterilant, dried, and returned to countertops or drawers. Disinfectant Checklist In selecting a disinfectant for instruments and other preparation room paraphernalia, keep in mind the characteristics of a good disinfectant: Has a wide range of activity (works against viruses, bacteria, and fungi) Is of sufficient strength (active against spore-forming organisms of bacilli and fungi) Acts in the presence of water Is stable and has a reasonably long shelf-life Is noncorrosive to metal instruments Fast-acting Is not highly toxic to living tissues or injurious to the respiratory system Care of the Embalming Machine After use, the embalming machine is flushed with warm water. Fluids that contain a humectant such as lanolin or silicon often leave a thick residue in the tank. Ammonia and lukewarm water flushed through the machine removes the residue. A water softener or a dishwasher detergent is also effective. Embalming machine cleaners are available from embalming chemical suppliers. After cleaning, fill the embalming machine one-third with fresh water to keep the silicone used to seal the tank wet. This prevents drying and shrinking of the seal and prevents leakage. Dissolved gases such as the chlorine found in tap water also have time to release before the next use of the machine. The later addition of embalming fluid to the water decreases the release of formaldehyde fumes. Place the lid on the tank of the machine in between use. Surfaces All preparation room surfaces should first be cleaned with cool water and a small amount of antiseptic soap to remove organic debris. A preliminary wash removes any debris and chemical residue present. Remember that many disinfectants, such as bleach contain chlorine, and this chemical should not come into contact with formaldehyde. Bleach and warm water make a very good cleaning solution. The table, countertops, and drains can be wiped clean and disinfected with this solution. Many commercially available products are also good disinfectants. Be certain to clean the area under the table surrounding the drainage outlet. Tops of overhead lighting should also be given attention. Tubing used for aspiration should be soaked in a disinfectant solution. Pay attention to handles on cabinets and drawers. Commercial products used for cleaning the preparation room contain dilution instructions. (Refer to Chapter 3 for a review of disinfection practices.) Instruments Clean Instruments Prior to Disinfection Removing organic material from the instrument makes disinfection more effective. Immerse all instruments including trocars in a cold sterilant solution according to product usage guidelines. Dispose of used cutting blades in a biohazard sharps container. Take special care with nondisposable cutting instruments when gas gangrene or tissue gas has been encountered. The causative agent of this condition, C. perfringens, is a spore-forming bacillus and can easily be passed via contaminated cutting instruments. They should remain in this solution several hours. After disinfection, instruments should be rinsed, dried, and properly stored (Fig. 15–19). Figure 15–19. Instruments properly stored after disinfection. Personal Hygiene Personal hygiene practices apply to the embalmer. Removal and disposal of PPE, handwashing, bathing and showering, laundering of washable garments, and other modes of hygiene are practiced after embalming. Best practice is to wear surgical scrubs instead of work attire beneath PPE. Include the cleaning of the nostrils of the nose where odors can linger. Nose hairs act as a natural filter, preventing the entry of foreign particles, such as dust and pollen, bacteria, spores, and viruses. Particles stick to the wet surfaces inside the nose to prevent inhalation. Harmful particles that are inhaled into the lungs may cause respiratory infections. DOCUMENTATION AND SHIPPING PREPARATION Complete the appropriate Embalming and Decedent Care Report for every deceased. The report should contain specific information related to the pre-embalming conditions of the deceased and personal effects received with the body. Inventory and document all personal items. Document all decedent care treatments performed. The report must accompany all bodies being prepared and shipped to another funeral facility. When the body has been autopsied before shipping, the report should indicate whether the viscera was retained by the postmortem examiner or returned with the body. Organs and tissues recovered for donation must also be noted. When viscera are treated during embalming and returned to the body cavities, note the method and chemicals used. Bodies should never be shipped without some form of covering. Place undergarments, hospital gown, plastic coveralls, or pants on the body. When positioning instructions have not been given by the receiving funeral home, make certain hands are not placed on top of one another. Place the hands separated, upon the abdomen. Resting one on top of the other can create indentations. The receiving establishment may prefer to reverse the hands for custom or preference. A light coating of massage cream or spray can be applied to the face and hands to prevent surface dehydration during shipping. Live floral arrangements that are placed inside of casket or shipping container can cause excess moisture. Certain flowers also have staining properties. All memorial items and personal effects placed into the container should be documented. Inform the receiving funeral home of the items and indicate where they will be found. PERIODIC MONITORING UNTIL FINAL DISPOSITION Periodic monitoring of the deceased and performance of the treatments necessary to maintain post-embalming stability is an ethical duty. Periodic surveillance is also called custodial care. The dignified care of all human remains is expected of all professional death care providers. Extended periods of storage prior to final disposition create additional opportunities for adjustments and corrections. These may include cosmetic and feature setting adjustments, treatments for discolorations, leakages and purges, the presence of mold, and infestations by insects. Potential areas of leakage could include: Any area of trauma to the face or hands where the skin was broken or torn Cranial autopsy incisions Autopsy sutures Surgical sutures Sutures at sites where vessels were raised for arterial injection Areas where edema is present Intravenous punctures Punctures used for drawing postmortem blood samples Any point where the skin has been broken Minor seepage (e.g., intravenous puncture) may be corrected by wiping away the accumulated liquid, injecting a phenol compound to cauterize the area, and sealing the puncture with a super adhesive. Where the skin has been torn, a phenol compound surface compress (or a cavity fluid compress) can be applied; later the area can be cleaned with a solvent, dried with a hair dryer, and sealed with a super adhesive glue. Clothing can be protected by sheets of plastic. The casket interior, pillow, and clothing should be inspected for any signs of leakage. If leakage is judged severe, the body should be removed from the casket and carefully undressed. Incisions can be opened, dried, checked to be certain vessels are ligated, and resutured using large amounts of incision seal powder within the incisions. Plastic garments can be placed on the body and, if necessary, edges sealed with mortuary tape. Interior damage may be severe enough to require replacement. Casket pillows can be reversed for minor leakage. Blankets and clothing may need to be replaced. Purge If purge has occurred, it will be necessary to reaspirate the body. No doubt the body will have to be taken back to the preparation room for this procedure. Not only should the body be thoroughly reaspirated, but the cavities should also be reinjected with undiluted cavity fluid. If gases were noted when the trocar button was removed, leave the body in the preparation room, if possible, for several hours and repeat the treatments again before redressing the body. The mouth and nasal cavities should be checked for dryness and tightly repacked with cotton or cotton webbing. The lips can then be resealed and cosmetics reapplied. Distended eyelids may indicate the presence of gases in the tissues. It may be necessary with this condition to aspirate the cranial cavity and inject some cavity fluid into the anterior cranial cavity. The presence of true tissue gas may necessitate reembalming of the body. Maggots Infestation of the body with maggots is a nightmare experienced by few embalmers today. In the summer months, bodies should be carefully examined for fly eggs, in particular the corners of the eyes, within the mouth, and the nostrils. If maggots are present, they can be picked from the surface of the body with cotton saturated with a hydrocarbon solvent. To stimulate maggots to emerge to the surface from areas beneath the skin or from the mouth or nostrils, the areas can be swabbed with a petroleum product. They should be placed in plastic bags before being discarded. The challenge with maggots is not knowing if all have been found. Maggots found on the clothing and hair can be vacuumed; properly clean the collecting canister on the vacuum. Mold In warm climates, mold can be a problem when bodies are being held for long periods. Bodies should be thoroughly dried to discourage mold growth. Mold needs to be carefully removed with a scalpel or spatula. The area is then swabbed with a phenol compound chemical and later thoroughly dried before cosmetics are applied. Placing embalming powder inside plastic coveralls, pants, and/or stockings helps to control mold growth. CONCEPTS FOR STUDY Define the following terminology: Accessory chemicals Baseball suture Bridge (individual) suture Capri pants Continuous (whip) suture Coveralls Crepitation Custodial care Double intradermal suture Hypodermic embalming Interlocking (lock) suture Inversion (worm) suture Pants Personal hygiene Shirt jacket Single intradermal (hidden) suture Stockings Surface embalming Terminal disinfection Tissue gas Unionall 1. Recall several post-embalming treatments. 2. Name the two types of supplemental embalming methods. 3. List several types of accessory chemicals. 4. Describe the internal hypodermic treatment method for reaching facial tissues. 5. Relate two methods of closing an incision. 6. Express the advantage of locking down a suture when closing a lengthy incision. 7. Explain the process for hiding the suture thread and knot at the completion of the closure. 8. Summarize terminal disinfection practices and personal hygiene for the embalmer. 9. State the benefits of plastic garments and body coverings for shipment of a deceased to another funeral establishment. 10. Define custodial care and defend its importance as a professional ethic of death care providers. FIGURE CREDIT Figures 15–1, 15–5, 15–18 are used with permission of Kevin Drobish. Figures 15–2, 15–3, 15–4, 15–8, 15–9, 15–12, 15–13, 15–15A-D, 15–16, 15– 17, 15–19 are used with permission of Sharon L. Gee-Mascarello. Figures 15–6, 15–7, 15–10, 15–11, 15–14 are used with permission of Kristine Miller. BIBLIOGRAPHY American Board of Funeral Service, Course Content Syllabus, 2016. Grant ME. Chronological order of events in embalming. In: Champion Expanding Encyclopedia, No. 571. Springfield, OH: Champion Chemical Co., October 1986. Venes D. Taber’s Cyclopedic Medical Dictionary, 19th ed. Philadelphia: F.A. Davis, 2001.