Table 1.

Flowchart of EPA technical execution.

Autopsy staff -First operator (the “dirty” one): doctor, specialist in pathology, expert in performing autopsies, even in presence of diseases with high infectious risk; performs the autopsy and, if necessary, sews the body at the end. -Second operator (the “clean” one): doctor, specialist or resident in pathology, even without particular autopsy experience; takes photographs, transcribes weights, measurements, volumes and observations dictated by the first operator and assists in the collection, cataloging and storage of the samples. -Technician: supports the first operator but only if he has been trained for autopsies at high infectious risk; if present, supports the first operator and sews the body at the end.

External inspection of the body -Body length, state of nutrition (maximum thickness of the adipose panniculus at the level of the chest and abdomen), skin (color, trophy and state of conservation), hair and nails, conjunctivae, sclerae, pupils, evaluation of any material that comes out from the mouth, nostrils or middle ear and, when possible, oral cavity and dentition. -Description of any pathological or morphological abnormality detectable on external examination of the body.

Scalp incision and opening of the skull -Bimastoid cut of the scalp, passing through vertex of the head. -The skull opening must be immediately suspended if there is a smell of bone dust in the environment: this fact indicates that the dust extraction system connected to the skull saw does not work. In this case the level of risk for the staff is unacceptable, due to biological microparticles free in the air. The operators must move away from the sector table for at least 20 min (time that guarantees at least 2 complete air exchanges in the autopsy room).

Evisceration of the brain -Cerebrum, brainstem and cerebellum must be maintained in their anatomical continuity. -Weigh the visceral block. -Take samples for electron microscopy and molecular investigations, preferably collecting on a single hemisphere or visceral hemibody, preserving the other for histopathological investigations. -Place the residual brain in formalin, suspending it inside the container; the brain suspension is made by passing a thin string under the basilar artery and knotting its ends at the joints of the handle of the container. -Remove the pituitary gland.

“Y” cut of the skin and subcutaneous planes for the examination of neck and trunk cavities and viscera -The “Y” cut is conducted from the two acromion processes to the xiphoid process of the sternum, and from this point to the pubis along the anterior median axis of the abdomen. -Observe the characteristics of the adipose tissue, the color and trophism of skeletal muscles, the state of congestion of major blood vessels and the possible presence of pathologies or injuries.

Opening of the rib cage -Assess the size of the cardiac area. -Assess the size of the visible areas of the lungs. -Assess the characteristics of pleural and pleural cavities. -Measure of the maximum height of the diaphragmatic dome.

Opening of the pericardial sac -Verify and quantify the presence of effusions or blood in the pericardial cavity. -Assess the characteristics of the pericardial and epicardial surfaces -Assess the content of the pulmonary veins by incision (any thrombi or clots must be taken and measured).

Opening in situ of the right chambers of the heart -Do not damage the cardiac conduction system, particularly the sinus-atrial node, the atrioventricular node and the bundle of His. -Evaluate the content of the right vessels and cardiac chambers (describing and quantifying the characteristics of any observed thrombi or clots). -Evaluate the morphology of the atrium, tricuspid valve, ventricular chamber, ejection cone, pulmonary valve and artery and its branches.

Opening in situ of the left chambers of the heart -Not open the ventricle ejection cone to avoid damaging the cardiac conduction system. -Evaluate the content of the left vessels and cardiac chambers (describing and quantifying the characteristics of any observed thrombi or clots). -Evaluate the morphology of the atrium, mitral valve, ventricular chamber, ejection cone, pulmonary valve and artery and its branches.

Eviscerate the heart -Weigh it and perform three biventricular sections from the tip towards the plane of the atrioventricular valves, on transverse planes, parallel to each other and about 1 cm apart. -On the most cranial section measure the thickness of the free walls of the two ventricles and that of the interventricular septum. -Take samples for electron microscopy and molecular investigations. -Place the heart completely in formalin for histological and immunohistochemical studies and, where appropriate, cardiac conduction studies.

Removal of the lungs by cutting them from the hilum -Weigh, macroscopically examine (external and internal parenchymal surfaces) and immediately sample, collecting all the lobes and areas with significant macroscopic differences (color, consistency, content at squeezing).

Individual evisceration, weighing, sampling and examination of: -Liver and gallbladder (in a single block). -Spleen. -Kidneys. -Adrenal glands. -Gonads.

Opening of the epiploon's back cavity

In situ inspection and sampling of: -Pancreas. -Ureters. -Bladder. -Uterus. -Prostate. -Abdominal tract of the aorta and the large retroperitoneal vessels. -Skeletal muscles. -Rib and relative bone marrow.

En bloc evisceration, sampling and examination of: -Tongue in continuity with the viscera of the neck and the posterior mediastinum. -Small intestine.

Mobilization, inspection and in situ sampling of: -Gut. -Colon.