Section 6.5: Embalming Challenging Cases

Section 6.5: Embalming Challenging Cases

Standard embalming procedures must often be modified to accommodate specialized pathological or post-mortem conditions. This section details five major challenging cases frequently encountered in the preparation room: edema, jaundice, autopsied remains, trauma, and decomposition.

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1. Edema (Anasarca)

Edema is the abnormal accumulation of fluid in the intercellular tissue spaces, pericardial sac, pleural cavity, or peritoneal cavity. Generalized edema is referred to as anasarca.

Embalming Complications of Edema

• Secondary Dilution: The excess water in the tissues dilutes the embalming solution, decreasing its preservative efficiency.
• Accelerated Decomposition: High moisture content speeds up autolysis and microbial growth.
• Tissue Distortion: Edema can stretch and distort the skin, especially in facial regions.
• Leakage: Fluid can seep through sutures, pores, or damaged skin, causing damage to clothing and casket interior.

Treatment Protocol

To remove excess water and achieve adequate preservation, the embalmer must establish a hypertonic solution.

1. Osmosis Principle: A hypertonic embalming solution (higher solute concentration than the tissue fluid) will draw the water out of the intercellular spaces and into the capillaries to be drained.
2. High-Index Arterial Fluid: Using high-index (25–35+) fluids creates a strong chemical concentration that counteracts secondary dilution.
3. Specialized Co-injectants: Formulated edema-reducing co-injectants (containing high molecular weight polymers or salts) help dehydrate tissue.
4. Epsom Salts (Magnesium Sulfate): If commercial co-injectants are unavailable, adding Epsom salts to the embalming solution increases its osmotic pressure, drawing water out of the tissues.
5. Restricted Cervical Injection: RCI allows the embalmer to inject a hypertonic, dehydrating solution into the edematous body, while injecting a milder, humectant-rich solution into the face to prevent facial dehydration.

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2. Jaundice (Icterus)

Jaundice, or icterus, is a condition characterized by a yellow discoloration of the skin, sclera, and tissues due to high levels of bilirubin in the blood (hyperbilirubinemia).

The Chemical Challenge

The primary hazard in jaundice cases is the chemical reaction between bilirubin and formaldehyde:

• Bilirubin (Yellow) is oxidized in the presence of strong acid or high-formaldehyde solutions into Biliverdin (Green).
• Once biliverdin is formed, it is a permanent post-mortem stain that cannot be resolved with cosmetics.

Jaundice Treatment Methods

To prevent the green discoloration, the embalmer must utilize specialized protocols:

• Low-Index Formaldehyde: Using a low-index (10–18) preservative solution reduces the risk of oxidation.
• Glutaraldehyde: Glutaraldehyde is an alternative aldehyde preservative. It is larger, reacts slower, and is less acidic than formaldehyde, making it far less likely to oxidize bilirubin into biliverdin.
• Active Cosmetic Dyes: Adding a large volume of active (staining) cosmetic dye (such as eosin or erythrosin) masks the yellow pigment and blends it into a natural flesh tone.
• Jaundice Fluids: Utilizing pre-formulated jaundice fluids that contain co-injection chemicals, active dyes, and mild preservatives.
• Pre-injection / Co-injection: Using a pre-injection wash to flush out as much unconjugated bilirubin as possible before introducing preservatives.

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3. Autopsied Remains

An autopsy (post-mortem examination) involves the removal and inspection of the internal organs. This procedure disrupts the continuous vascular loop, requiring a sectional injection protocol.

Sectional Injection Protocol

During a complete autopsy, the ascending aorta and the arch of the aorta are removed along with the heart. This destroys the central distribution point of the arterial system. Consequently, the body cannot be embalmed via a single injection point. The embalmer must perform sectional injection, isolating and injecting six main arteries to preserve the body:

Treatment of the Viscera

• The viscera (organs) are usually returned in a plastic bag inside the body cavity or in a separate container.
• The viscera should be cut open to allow chemical penetration and saturated in concentrated cavity fluid or autopsy gel.
• Prior to closing the body, the empty thoracic and abdominal cavities should be painted with autopsy gel and lined with hardening compound to absorb moisture.

Securing the Head and Skull

• The internal carotid arteries must be clamped or tied within the cranial vault to prevent fluid from leaking during head injection.
• After injection, the cranial vault is dried, painted with gel, and packed with cotton or quick-drying plaster.
• The calvarium (skull cap) is secured back in place using calvarium clamps, wiring, or temporalis muscle sutures.
• A intradermal suture is used to close the scalp, starting from the right ear to the left ear.

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4. Trauma

Trauma cases (e.g., motor vehicle accidents, gunshot wounds, blunt force trauma, falls) present combined challenges of vascular disruption, swelling, and tissue loss. Embalming must be highly customized and coordinated with future restorative art procedures.

Embalming Protocols for Trauma

1. Restricted Cervical Injection (RCI): RCI is critical. It allows the embalmer to isolate the head and prevent facial swelling, which is highly common in head injuries, while high pressure and high-index fluids can be used on the body.
2. Sectional Injection: Using undamaged arteries to bypass severed vessels. For example, if the femoral artery is ruptured, the embalmer may inject the lower leg via the popliteal or tibial arteries.
3. Hypodermic & Surface Treatments: Areas that cannot be reached arterially due to vascular rupture must be injected hypodermically with cavity fluid or treated with surface packs containing phenol or cavity fluid.
4. Suturing & Reconstruction: Lacerations should be aligned and sutured using tight, leak-proof stitches (like the bridge suture for temporary alignment, or intradermal/lock sutures for final closure).
5. Correlation with Restorative Art: Embalming must dry and firm the tissues completely. If tissues are soft or wet, wax and cosmetics will not adhere. Surface packs (using cavity fluid or phenol) are applied to dry up skin abrasions and lacerations.

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5. Decomposition

Decomposition is the breakdown of organic matter after death. It is characterized by five signs: color change (green/black over abdominal quadrants), odor (due to amines like putrescine and cadaverine), skin slip (desquamation), purge (evacuation of stomach, lung, or brain contents), and gas (tissue gas or wet gangrene).

Chemical Challenges of Decomposition

• High Preservative Demand: Decomposition causes a massive increase in formaldehyde demand due to the breakdown of proteins into nitrogenous waste (ammonia, which neutralizes formaldehyde).
• Vascular Breakdown: Capillary walls and larger vessels break down, leading to poor fluid distribution and premature leakage.
• Autolysis: Enzymes digest cells, leaving tissues soft, fluid-filled, and unable to firm up easily.

Treatment Protocol for Decomposition

• High-Index Fluid: Use index 30+ to satisfy the high preservative demand.
• Waterless Embalming: A mixture of arterial fluid, co-injection fluid, and active dye, without adding tap water, to maximize preservation and prevent tissue swelling.
• Sectional Injection & Hypodermic Treatment: Direct injection into areas lacking distribution.
• Double Cavity Treatment: Thorough aspiration and injection of 32–48 ounces of cavity fluid. Re-aspiration and re-injection are mandatory 24 hours later.
• Deodorizing & Disinfection: Washing the body with disinfectant soap and using topical deodorizing sprays or powders to manage smell.