EMBALMING VESSEL SITES AND SELECTIONS

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CHAPTER 9

• EMBALMING VESSEL SITES AND SELECTIONS

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Terminology

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

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Terminology

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

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Terminology

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

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Terminology

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

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Terminology

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

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Terminology

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

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Vessel Selection

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

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Vessel Selection

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

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General Considerations of Vessel Selection

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

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Nerve Characteristics

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

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Vein Characteristics

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

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Artery Characteristics

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

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Selecting an Artery

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

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Selecting an Artery

• Criteria that should be considered when
  contemplating an injection site. (mutilation?)
• How close to the aorta is the artery? Remember
  the closer the vessel to the aorta the better
  the results.
• What is the diametric size of the artery? Is it
  so small you dont have a canula to fit in it?
  Or is it large enough to be able to use a
  decent amount of pressure?

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Selecting an Artery

• Can the body be positioned properly if this
  artery is used?
• Unless youre trying to get instant fixation of
  the tissue any artery can be used and the body
  positioned immediately after injection, such as
  the axillary.

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Selecting an Artery

• Will incisions for the artery be on an exposed
  body area?
• This is why I have never the seen the facial
  artery used. Also, funeral directors used to
  ask families to bring in a dress with a high
  neck line for the women so the incision wouldnt
  show. Today, a good embalmer doesnt need to
  hide behind a high neck dress.

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Selecting an Artery

• Can drainage be taken from the vein which
  accompanies the artery?
• An example of where drainage potentially
  wouldnt be taken would be the radial and ulnar.
  The veins are so small that it wouldnt be
  worth cutting and would only give you another
  incision to have to seal.

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Selection of the Artery

• Other factors to include when selecting an artery

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Age of the Deceased

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

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Gender

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

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Weight

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

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Fat Distribution

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

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Disfigurations Present

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

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Disease Conditions

• Examples include
• Gangrene- Dont use the vessels where there are
  signs of gangrene, it is probably a sign that
  there is poor blood supply.
• Burned Tissue- Avoid burned tissue if possible as
  leakage will be a problem when suturing.

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Edema, Localized or General

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

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Interruption of the Vascular System

• Mutilation 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.

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Interruption of the Vascular System

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

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Interruption of the Vascular System

• Autospies- Depending on the type of autopsy
  partial or complete, the embalmer may have to
  choose which vessels to use.

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Trauma

• Trauma may be present from
• mutilation
• accident
• surgery

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Medico-Legal Requirements

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

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Cause of Death

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

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Manner of Death

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

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Clotting

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

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Facial Tissue Distension

• Always use a restricted cervical injection if
  facial tissue distension is present or if it
  becomes an issue.

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Facial Discoloration

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

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Volume and Strength Arterial Solution

• If the embalmer needs to use a large volume of
  fluid with a strong solution then a restricted
  cervical injection should be used to avoid over
  injection of the fluid to the facial tissue.

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Size of the artery

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

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Elevation and Ligation of Vessels
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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.)

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The 10 steps to raise a vessel

• 4. Make the incision.
• 5. Dissect the muscle to get to the vessel, dont
  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.

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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.

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The 10 steps to raise a vessel

• 10. If the artery is accidently broken the ends
  must be found and closed before a new arterial
  tube can be inserted.

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Instruments

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

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Instruments

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

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Instruments

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

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Ligature

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

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Common Carotid Artery
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Regions Supplied

• The head and face if in injection is superior.
• The entire body if the injection is inferior.

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Pros- IT IS

• large,
• easily raised to the skin surface,
• elastic,
• rarely found to be sclerotic,
• the artery that supplies fluid directly to the
  head,
• close to the arch of the aorta,
• accompanied by a large vein (the jugular),
• helpful in moving blood clots away from the head.

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Cons

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

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Incision

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

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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.)

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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.

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Protocol for raising the Carotid

• Open the vein and insert a drain instrument.

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Internal Jugular Vein
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Pros, IT IS

• large,
• the vessel that provides direct drainage from the
  face and head,
• accompanied by the common carotid artery,
• close to the superior vena cava allowing easy
  removal of blood clots.

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Cons

• Leakage may be visible.
• Drainage instruments if used improperly may mark
  the face.
• The incision may be visible with some clothing.
• These are the same cons at the common carotid
  artery as the incision is made in the same place.

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The Restricted Cervical Injection

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

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(No Transcript)
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Facial Artery
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When Used

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

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Supplies Fluid To The

• Soft tissue of the face
• Upper and lower lips
• mouth area
• side of the nose
• medial tissue of the face
• lower eyelid

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Suturing can be done with

• Super Glue
• Dental Floss

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Axillary Artery
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Regions Supplied

• Directed toward the hand it supplies the arm and
  the hand.
• Directed toward the body it supplies everything.

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Pros

• The arterial solution flows directly into the arm
  and hand.
• Close to the face.
• It is a superficial vessel.

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Cons

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

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Incision

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

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Axillary Vein

• The vein is found medial and superficial to the
  axillary artery.

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Protocol for raising the artery

• The steps are the same as the common carotid
  artery.

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Brachial Artery
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Supplies

• Arm
• Hand

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Vein

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

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Incision

• Anywhere along the upper half of the linear guide.

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Radial Artery
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Characteristics

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

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Ulnar Artery
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Characteristics

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

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Femoral Artery
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Supplies

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

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Pros

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

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Pros

• The head and arms can be posed with out having to
  be further manipulated after embalming.

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Cons

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

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Incision

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

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Femoral Vein
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Pros

• Large.
• Clean method of drainage.

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Cons

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

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Popliteal Artery
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Characteristics

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

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Characteristics

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

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Anterior and Posterior Tibial Arteries
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Characteristics

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

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External and Internal Iliac Artery
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Characteristics

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

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

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

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Characteristics