General Considerations

The term "high risk," as applied to autopsy, is generally used to refer to those autopsies in which there
is a high risk of transmission of disease to those doing the autopsy. Universal precautions should be
used in the performance of all autopsies, because any patient coming to autopsy may have an
undiagnosed high-risk condition. Universal precautions include but are not limited to wearing 2 pairs
of rubber gloves (ie, "double gloving") for handling tissues or blood, as well as wearing eye protection,
cap, gown (or "space suit"), mask, plastic apron, sleeve covers, and shoe covers; these items should
be worn by anyone participating in the autopsy dissection. (See also CBRNE - Personal Protective
Equipment.)
Frequent changing of the outer gloves is commonly recommended. Cut-resistant stainless steel mesh
or fabric gloves are sometimes recommended. [1] They protect against scalpel injury but not against
needle puncture. However, because such gloves reduce tactile sensation, some pathologists find
them cumbersome.[2] Latex gloves that are available in supermarkets and that are designed to protect
the hands during dishwashing or cleaning are much thicker than surgical gloves or examination
gloves. These gloves can represent a compromise between cut-resistant "chain mail" gloves and
regular hospital rubber gloves, but they are unsuitable for persons who have an allergy to latex.
In general, anyone in the autopsy room who may come in contact with blood, body fluid, or tissue
should wear disposable protective "rubber" gloves. Any surface of the body that might come in contact
with blood or body fluid should be protected by impervious material (such as a plastic apron). Face
protection should be worn when splashing or splattering of blood or body fluid is possible. A mask is
worn to prevent inhalation of aerosols; a face shield is worn to protect the mucous membranes of the
eyes, nose, and mouth from exposure to splash. The high-risk infections transmitted by aerosols
are tuberculosis, rabies, viral hemorrhagic fever, anthrax, and plague; human immunodeficiency virus
(HIV) is not transmitted by aerosols.[2]
Prosectors should limit their activities to the autopsy table and dissecting area. There should be only 1
blade in the dissection field at any time. A "clean" circulating assistant should be available to obtain
additional instruments, to take notes, and to answer the telephone. Specimens for microbiologic
culture and cassettes of microscopic sections should be placed in a container; the outside of the
container should be free of blood and body fluids from the autopsy. These containers should be put
into an impermeable bag for transport to the microbiology and histology laboratories. The paperwork
needed to accompany the containers should be free of blood or body fluids. Paperwork that is
contaminated by blood or fluid should be replaced by uncontaminated copies of the paperwork before
the paperwork leaves the autopsy room.
Needles should not be purposely bent, clipped, recapped, or otherwise manipulated by hand. A
puncture-resistant container designed for the disposal of sharp instruments should be within easy
reach of the prosector. Needles, syringes, and scalpel blades should be dropped into this container
immediately after use. Needles should not be removed from syringes before disposal. Scalpel blades
should be removed from their handles with the use of devices designed for this purpose or with a
forceps; the tip of the blade should be aimed at the cutting board during removal. Some authorities
advocate using one's hand to slip the blade off the scalpel handle; this decreases the possibility that
someone struggling to remove a blade may inadvertently propel it into another person. Before leaving
the autopsy table, the prosector should remove all scalpel blades from their handles and dispose of
the blades immediately after completing the autopsy dissection and sectioning.
Additional measures enhance safety in the autopsy room even further. For most dissections, blunttipped scissors may be used instead of a scalpel. [3] Tissue may be held for dissection or sectioning
with a forceps instead of with the noncutting hand. The ribs may be cut with a large gardening shearstype instrument. A plastic bag or tent may be placed around the mechanical saw while it is being used
to cut the skull and spine.[4]
Surgical towels may be placed over the cut edges of the rib cage while the chest is being eviscerated
and the thoracic spine and spinal cord cut. When slicing an organ, a sponge or stack of paper towels
may be put on top of the organ between the organ and the noncutting hand holding the organ in place
while it is being sliced. Scalpels may be placed on a flat surface for the prosector to pick up rather
than handed to the prosector.

In general, anyone handling a scalpel or other sharp instrument should shut out distractions while
cutting with it; the scalpel should then be set down in plain view in a cleared space. Before moving a
sharp instrument, one should announce to all nearby persons that the instrument is being moved.
Obtaining microscopic sections, which requires the use of a scalpel, may be done the day after an
autopsy, after the tissue intended for sectioning has been fixed.
Additional suggestions for further enhancing safety in the autopsy room are not all practical. Some
authors have suggested that the scrub suit worn while performing an autopsy should not be worn
outside the autopsy room. This would require that the prosector strip down to his or her underwear
before leaving the autopsy room.
Should a needlestick or scalpel cut involving exposure to blood or body fluid occur, the injured person
should stop dissecting immediately, allow the wound to bleed freely, wash the wound with soap and
water, and then apply disinfectant to the wound. HIV is inactivated by a wide range of disinfectants,
including iodophor compounds (such as Betadine), 60% ethanol, 3% hydrogen peroxide, phenolic
compounds (such as Lysol), formaldehyde solution (formalin), and sodium hypochlorite (household
bleach, Clorox) in a freshly prepared 1:10 dilution in water (final concentration, 0.5%).
Rules and policies are limited in their ability to prevent harm and require mindfulness by those who
are supposed to follow them to be effective. Furthermore, situations outside the scope of rules and
policies often arise. Thus, perhaps the most important safety measure a prosector can take for
preventing transmission of infection at autopsy is to have a safety-first mindset

Specific Types of High-Risk Autopsies

Many, if not most, high-risk autopsies are known to be such before the autopsy is performed; this is
certainly the case in the hospital setting. In North America and Europe, 4 high-risk agents elicit the
greatest concern about the transmission of disease during autopsy: HIV, hepatitis C virus
(HCV), Mycobacterium tuberculosis,and Creutzfeldt-Jakob prion. Hepatitis B virus (HBV) would be
included among these agents of greatest concern except for the fact that almost all healthcare
workers are vaccinated against it; anyone performing autopsies certainly should be vaccinated
against HBV.
A more complete list of high-risk infections includes rabies, Hantaan virus infection,West Nile
Encephalitis, lymphocytic choriomeningitis, human T-cell lymphotropic virus type I, Ebola virus, Lassa
fever, South American hemorrhagic fever, the various encephalitis virus infections, dengue
fever, yellow fever, Yersinia pestisinfection (plague), typhoid fever, Bartonella infections (ie, catscratch
disease, trench fever, Oroya fever), tularemia, anthrax, brucellosis, melioidosis, and meningococcal
infection.
There is no universal agreement as to which infections are to be considered high risk; some
authorities include many more. In general, diseases other than the 4 listed above are rare, and the
few that are not rare are not as serious. For example, catscratch disease is usually self-limited and
usually requires no therapy.
Methicillin-resistant Staphylococcus
aureus (MRSA),
vancomycin-resistantEnterococcus
faecium (VREF), multidrug-resistant Pseudomonas aeruginosa, multidrug-resistant Acinetobacter
baumannii-haemolyticus, and other multidrug-resistant bacteria that represent normal flora are a
concern at autopsy, but the risk that these agents will cause illness in those performing an autopsy is
not high. The concern is to avoid spreading these agents outside the autopsy room. To prevent such
spread, protective garments that have blood or body fluids on them should be taken off before leaving
the autopsy room.

In cases of high-risk infection, evisceration and dissection may be carried out without scalpels, and
sectioning may be postponed until the dissected organs have been fixed in 10% formalin; this cannot
be done, however, without compromising the autopsy investigation. If large organs such as the liver
are not cut into before they are immersed in fixative, many days would be required for the formalin to
penetrate to the center of the organ; during that time, autolysis will have obliterated the histology, and
the provisional autopsy (PAD) report will be delayed well past the 2 working days required for College
of American Pathologists (CAP) laboratory certification. Previous fixation also makes microbiologic
cultures impossible.
If mycobacterial infection is discovered, polymerase chain reaction (PCR) testing may be performed
on the fixed tissue to determine whether the infection is tuberculosis and, if it is tuberculosis, whether
it involves a multidrug-resistant strain. However, these tests are designed for use in blood samples
from living patients; they may not work on fixed autolyzed autopsy tissue.
If the presence of pulmonary tuberculosis has already been documented, the lungs may be insufflated
with formalin before sectioning. If one is willing to forgo microbiologic culturing and if the local funeral
directors permit it, the entire body may be embalmed before autopsy. (Embalmed and exhumed
bodies will be discussed in a separate article.)