chapter 9 embalming vessel sites and selections. terminology one-point injection- one artery and...
TRANSCRIPT
CHAPTER 9
EMBALMING VESSEL SITES AND
SELECTIONS
TERMINOLOGY
O
ne-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.
S
plit 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
R
estricted 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
M
ulti-point Injection- Injection from two or more arteries.
Example: injecting the carotid and the femoral to
achieve the desired results.
T
ypes are:• Restricted cervical injection• Six-point injection• sectional vascular injection
TERMINOLOGY
S
ectional 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:
TERMINOLOGYF
ace and Head: Common carotid artery
U
pper Extremity: Subclavian, axillary, brachial artery
H
and: radial or ulnar artery
L
ower Extremity: Common iliac, external iliac, femoral artery
B
ody Trunk: in the un-autopsied body, injection of any major artery toward the
trunk region.
TERMINOLOGY
S
ix-Point Injection: Six arteries are raised to inject the
head and limbs.
T
hey are:• right and left common carotid arteries• right and left axillary (or brachial)• right and left femoral (or external iliac)
VESSEL SELECTION
I
n the unautopsied body the arteries most frequently used
for embalming are the:• common carotid• femoral, and• axillary arteries.
M
ost cases start out as a one-point injection but require
additional vessels to be raised to achieve the desired results.
VESSEL SELECTION
H
ow 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
T
he 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
N
erves 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
eins 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
A
rteries 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
A
s 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
C
riteria that should be considered when contemplating an
injection site. (mutilation?)
H
ow close to the aorta is the artery? Remember the closer
the vessel to the aorta the better the results.
W
hat 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 to be
able to use a decent amount of pressure?
SELECTING AN ARTERY
C
an the body be positioned properly if this artery is used?
U
nless 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
W
ill incisions for the artery be on an exposed body area?
T
his 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 need to
“hide” behind a high neck dress.
SELECTING AN ARTERY
C
an drainage be taken from the vein which accompanies the
artery?
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
I
nfants- the carotid artery is the largest and should
be selected for that reason.
E
lderly- many times the femoral artery is sclerotic so
it is not chosen first.
GENDER
W
hat 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
I
n obese bodies the femoral artery is very deep and
may not be able to be used.
I
n very thin bodies the SCM can be pronounced and
care should be taken when using the carotid the
protect the SCM.
FAT DISTRIBUTION
P
eople 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
E
xamples are:• arthritic conditions• tumors• scar tissue
T
ry 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
E
xamples include:
G
angrene- Don’t use the vessels where there are signs of
gangrene, it is probably a sign that there is poor blood supply.
B
urned Tissue- Avoid burned tissue if possible as leakage will
be a problem when suturing.
EDEMA, LOCALIZED OR GENERAL
G
eneralized edema is called anasarca.
W
hen 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.
L
arge quantities of fluid should be injected for generalized edema.
INTERRUPTION OF THE VASCULAR SYSTEM
M
utilation or Trauma: car accidents or accidental
death can result in severed arteries. These bodies
require more than one point of injection and the the
several arteries will have to be clamped during the
injection.
INTERRUPTION OF THE VASCULAR SYSTEM
U
lceration'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
A
utospies- Depending on the type of autopsy; partial
or complete, the embalmer may have to choose
which vessels to use.
TRAUMA
T
rauma may be present from:• mutilation• accident• surgery
MEDICO-LEGAL REQUIREMENTS
T
his can include:• preparation for medical schools• international shipping• under military contracts• coroner or medical examiner
E
ach of these situations may have written protocol the
embalmer must follow.
CAUSE OF DEATH
E
xample- depending on how a person died you may or
may not have all of the arteries available to you for
selection.
MANNER OF DEATH
E
xample- a bullet wound could sever a major artery
and make it unavailable for selection.
E
xample- a natural death of a person could mean that
you have all the arteries available to you for
selection.
CLOTTING
I
f 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
A
lways use a restricted cervical injection if facial
tissue distension is present or if it becomes an issue.
FACIAL DISCOLORATION
M
any 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
I
f 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
U
se 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
1
. Select the instruments and prepare the thread you will be
using. ( You will probably have a tray will all the instruments you
need for the embalming.)
2
. Locate the vessel by the linear guide.
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
4
. Make the incision.
5
. Dissect the muscle to get to the vessel, don’t cut it..
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
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.
8
. If clotted material is present, try and remove it before inserting the
arterial tube.
9
. Search for the softest portion of the artery to insert the arterial tube.
THE 10 STEPS TO “RAISE” A VESSEL
1
0. If the artery is accidently broken the ends must be
found and closed before a new arterial tube can be
inserted.
INSTRUMENTS
S
calpel- Used for making the incision.
D
ouble-point scissors- Used for making the incision and cutting the ligature.
A
neurysm needle- Used for dissecting fat and fascia; elevating vessels at
surface.
B
one Separator- Used for elevating vessels at the skin surface.
INSTRUMENTS
A
rterial Tubes- Used for insertion into the artery for injection of the fluid.
D
rainage Tube- Used for insertion into the vein for drainage control.
A
ngular Spring Forceps- Used for insertion into the vein for drainage
control.
S
traight Spring Forceps- Used for passing ligatures around the vessels.
INSTRUMENTS
G
rooved Director- Used for assisting in the expansion
of the vein for insertion of the drainage device.
LIGATURE
L
igature is a fancy word for string.
U
sually the string that an embalmer uses is heavy and thick and made of
linen or cotton.
M
any embalmers use dental floss to sew cranial autopsy’s and the right
carotid incision when a hidden stitch is used.
T
he ligature should be 8 to 12 in. in length.
COMMON CAROTID ARTERY
REGIONS SUPPLIED
T
he head and face if in injection is superior.
T
he entire body if the injection is inferior.
PRO’S- IT IS:
l
arge,
e
asily raised to the skin surface,
e
lastic,
r
arely found to be sclerotic,
t
he artery that supplies fluid directly to the head,
c
lose to the arch of the aorta,
a
ccompanied by a large vein (the jugular),
h
elpful in moving blood clots away from the head.
CON’S
T
he head may be over injected.
I
f leakage occurs, it may be seen.
S
ome types of instrument may mark the side of the face or jaw line if
used improperly.
T
he incision may be visible with some types of clothing.
INCISION
T
he 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
1
. Stand at the head of the embalming table.
2
. Turn the head to the left to raise the right common carotid.
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
4
. Make the incision.
5
. Find the SCM muscle at the clavicle.
6
. Raise the internal jugular vein and tie it off.
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
O
pen the vein and insert a drain instrument.
INTERNAL JUGULAR VEIN
PRO’S, IT IS:
l
arge,
t
he vessel that provides direct drainage from the face and head,
a
ccompanied by the common carotid artery,
c
lose to the superior vena cava allowing easy removal of blood
clots.
CON’S
L
eakage may be visible.
D
rainage instruments if used improperly may mark the face.
T
he incision may be visible with some clothing.
T
hese are the same con’s at the common carotid artery as the
incision is made in the same place.
THE RESTRICTED CERVICAL INJECTION
P
rocedure:• 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
I
n bodies that been autopsied and the carotids or
portion of are removed.
I
n bodies with clotting or sclerosis of the carotid
artery.
SUPPLIES FLUID TO THE:
S
oft tissue of the face
U
pper and lower lips
m
outh area
s
ide of the nose
m
edial tissue of the face
l
ower eyelid
SUTURING CAN BE DONE WITH:
S
uper Glue
D
ental Floss
AXILLARY ARTERY
REGIONS SUPPLIED
D
irected toward the hand it supplies the arm and the
hand.
D
irected toward the body it supplies everything.
PRO’S
T
he arterial solution flows directly into the arm and
hand.
C
lose to the face.
I
t is a superficial vessel.
CON’S
T
he arm must be extended.
T
he artery is small to use for injection of the entire body.
T
he accompanying vein is small.
T
he facial tissue could be over injected if injection is directed toward the head.
T
here are numerous branches.
INCISION
T
he arm is extended from the body.
T
he incision is made parallel to the linear guide.
AXILLARY VEIN
T
he vein is found medial and superficial to the axillary
artery.
PROTOCOL FOR RAISING THE ARTERY
T
he steps are the same as the common carotid artery.
BRACHIAL ARTERY
SUPPLIES
A
rm
H
and
VEIN
T
he accompanying vein is the basilic and is difficult to
use because it is so small.
INCISION
A
nywhere along the upper half of the linear guide.
RADIAL ARTERY
CHARACTERISTICS
S
upplies:• Thumb side of the hand.
L
ocation:• Superficial area of the wrist.
I
ncision:• Parallel to the artery directly on the linear guide about 1 inch
above the base of the thumb.
ULNAR ARTERY
CHARACTERISTICS
S
upplies:• medial side of the hand.
I
ncision:• Made parallel to the vessel directly over the linear
guide.
FEMORAL ARTERY
SUPPLIES
W
hen directed toward the foot, supplies the leg and
foot.
W
hen directed toward the head, supplies the entire
body.
PRO’S
L
arge.
I
ncision is not visible.
B
oth sides of the head may receive even distribution.
A
ccompanied by a large vein for drainage.
N
o solution has to pass under the body as with the carotid.
PRO’S
T
he head and arms can be posed with out having to be
further manipulated after embalming.
CON’S
M
ay be sclerotic.
M
ay lie deep.
N
o control of the solution entering the head.
C
oagula may be pushed into the head and arms which are viewed.
O
ther large arteries around it may be mistaken for it.
INCISION
T
his 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
L
arge.
C
lean method of drainage.
CON’ST
he weight of the viscera can restrict drainage from the upper part of the
body.
A
bdominal pressure can restrict drainage by putting pressure on the vein.
T
he vein is deep in obese people.
V
eins around it can be ruptured easily.
C
lots in the rest of the body can be hard to remove.
POPLITEAL ARTERY
CHARACTERISTICS
S
upplies:• The area below the knee.
E
xamples of when it is used:• mutilated bodies• accidental deaths• arthritic bodies
T
he accompanying vein is not used.
CHARACTERISTICS
I
ncision:• Down the center of the Popliteal space parallel to
the artery or• Just superior to the Popliteal space.
ANTERIOR AND POSTERIOR
TIBIAL ARTERIES
CHARACTERISTICS
S
upplies:• foot
L
ocation:• they are deep making them hard to find.
EXTERNAL AND INTERNAL ILIAC ARTERY
CHARACTERISTICS
I
n the autopsied body the external iliac artery supplies
solution to the lower extremity and the anterior
abdominal wall.
I
n the autopsied body the internal iliac artery supplies
solution to the gluteal and the peroneal regions.
I
am skipping :• Abdominal Aorta and Thoracic Aorta• Inferior Vena Cava• Right Atrium of the Heart
I
t 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
T
he most common incision is the transverse incision.
A
s soon as you see the lumen STOP CUTTING!
CHARACTERISTICS