DEFINATION

Shock give rise to systemic hypoperfusion caused by reduction either in

cardiac output or in effective circulatory blood volume.

End results are:

Hypotension

Tissue hypoperfusion

Cellular hypoxia

Reversible injury

Irreversible injury with persistent of shock

End organ dysfunction

Death

TYPES OF SHOCK

• Hypovolumic shock

• Cardiogenic shock

• Septic shock

⚫Anaphylactic shock
• Neurogenic shock

HYPOVOLUMIC SHOCK

Hypovolumic shock occurs due to rapid reduction in blood volume or plasma

volume.

Causes of hypovlumic shock:

1. Hemorrhage

2. Severe dehydration-severe vomiting, severe diarrhea

3. Severe burn

4. Abdominal ascities

5. Acute pancreatitis

6. Diabetes mellitus

HYPOVOLUMIC SHOCK

Pathophysiology of hypovolumic shock

Dehydration, Hemorrhage
Reduction in intravascular blood volume

Decreased pre-load

Decreased stroke volume & CO

Systemic hypoperfusion

Compensatory vasoconstriction

Tissue ischemia, hypoxia

Cellular & organ dysfunction

CARDIOGENIC SHOCK

• Cardiogenic shock is characterized by reduced pumping ability of heart due

to intrinsic myocardial damage or extrinsic or obstruction to out flow. It is
most commonly occurs in association with and as a direct result of acute
myocardial ischemia.

Incidence:

-Cardiogenic shock occurs in 8.6% of patient with ST segment elevation.

-Myocardial ischemia with 29% of those presenting to the hospital already in

shock.
-2% of non ST segment elevation MI.

CARDIOGENIC SHOCK

• Risk factor:

-Pre existing myocardial damage

-Diabetes Mellitus

-Advanced age

-Previous MI

-Dysarythmia

CARDIOGENIC SHOCK

Causes of Cardiogenic shock:

MI

• Vulvular regurgitation

• Acute myocarditis • Cardiomyopathy

• Cardiac tamponade
• Pulmonary embolism

Acute vulvular dysfunction

• Cardiac dysarythmia

Rupture ventricular aneurysm

Beta-blocker overdose

Ca-channel blocker overdose

CARDIOGENIC SHOCK

Pathophysiology of cardiogenic shock:

Myocardial Infraction

Myocardial ischemia or injury

Myocardial dysfunction

Systemic inflammatory response

Decreased CO & stroke volume

Increased NO synthesis
Systemic hypoperfusion

Hypotension

Vasodilatation

Decreased coronary perfusion

Compensatory vasoconstriction

>Cardiac & other end organ damage

Progressive myocardial dysfunction

Death

SEPTIC SHOCK

• Sepsis is a clinical state that accompanies infection either confined to a

local site from which toxin are absored or associated with invasion of
organism in to the blood stream.

• Causes of septic shock:

-Overhelming microbial infection

-Gram +ve septicemia

-Endotoxic shock (Gram-ve septicemia)

-Fungal sepsis

-Super antigen

SEPTIC SHOCK

• Predisposing factor:

Increased life support for high risk patient

Advanced age

Debilitating illness

Increasing use of invasive procedure

Disseminated malignancy

Increased number of immuno-compromised host

-Secondary to malignancy

-Immuno-supression
-HIV infection

SEPTIC SHOCK

Microbiology:

Other

Gm - Fungi

Gm +

E.Coli

Staphylococcus

Klebsiella

Streptococcus

Proteus

SEPTIC SHOCK

Pathophysiology of septic shock:

Bacterial infection
Endotxin (LPS) & other microbial products

Binds to LPS binding protein in serum

Binds to CD14 receptors on mononeuclear cells

CD14 binds to TLR4

Release of chemical mediators

SEPTIC SHOCK

• Immuno suppression:

hyper inflammatory state activate immuno- suprssion mechanism which

involve both innate & adaptive immunity by production of anti- inflammatory
mediators(soluable TNF receptors, IL- recepor antagonist& IL-10).

Organ dysfunction:

Systemic hypotension, interstitial edema, small vessels thrombosis reduce

the delivery of oxygen &to the tissue.

SEPTIC SHOCK

• High level of cytokines, secondary mediators reduces myocardial

contractility & CO. Increase vascular permeability & endothelial injury acute
respiratory distress syndrome ultimately cause multiple organ failure.
• Toxic shock syndrome:

Toxic shock syndrome is a potentially fatal illness caused by bacterial

toxin(super antigen) released by - Staphylococcus aureus & Streptococcus
pyogens.

Streptococcal TSS associated with recent soft tissue injury like surgery,
pharyngitis, NSAID drug use.

Staphylococcal TSS observe mostly among menstruating women, but also

associated with cutaneous infection, post-partum & C/S wound infection &
focal staphylococcal infection like abscess, empyma, pneumonia

ANAPHYLACTIC SHOCK

In Anaphylactic shock, decreased systemic vascular resistance due primarily

to massive histamine release from mast cell after activation of IgE mediated
hypersensitivity reaction as well as increase synthesis of prostaglandin. That
leads to vasodilatation and increase vascular permiability. Ultimate results
are systemic hypotension, tissue perfusion and cellular anoxia.

ANAPHYLACTIC SHOCK

• Causes of anaphylactic shock:

1.latrogenic(drug)

2.Accidental exposure to an allergen and co-exiting respiratory

complaints(wheezing & dyspnea) & or purities.
• Systemic inflammatory response in anaphylactic shock:

Respiratory distress

Wheezing

Urticarial rash

Angioedema.

STAGES OF SHOCK

1.An initial non progressive phage

2.A progressive stage

3.An irreversible stage

An initial non progressive phage:

In this phage a varieties of neuro-hormonal & haemostatic mechanism helps

to maintain cardiac out-put & blood pressure. These includes:

- Baro-receptor reflex mechanism

- Release of catecholamine's

- Activation of Renin-angiotension axis

- Anti-diuretic hormone release

-Generalized sympathetic activation

• Net effects are- 1. Tachycardia

2. Peripheral vasoconstriction

3. Renal conservation of fluid

Resulting in restoration of circulation and tissue perfusion.

• Progressive phase:

If the compensatory mechanism fails to restore circulation, vital organ shows

the effects of hypoxia. Persistant oxygen deficiency leads to intra cellular
anaerobic glycolysis with lactic acidosis, thus reduce tissue pH and
vasomotor response. Resulting reduce cardiac output and anoxic injury to
endothelial cell leads to DIC.

• Irreversible stage:

When there is failure to restore circulation either by compensatory

mechanism or by therapeutic intervention, the process of shock enters the
irreversible stage. Wide spread cell injury is reflected in lysosomal enzyme
lekage, nitric oxide reduced myocardial contractility, acute tubular necrosis
ultimately death.

MORPHOLOGY OF SHOCK
• Since shock is characterized by failure of multi-organ systems, the cellular
changes may appear in any tissue.

Brain: ischemic encephalopathy.

Heart: coagulative necrosis or subendocardial hemorrhage or contraction

band necrosis.

Kidney: acute tubular necrosis.

Lung: diffuse alveolar damage develop shock lung.

Gastrointestinal tract: Hemorrhagic enteropathy.

Adrenal gland: cortical cell lipid depletion may occur.

Liver: fatty change, central hemorrhagic necrosis.

CLINICAL PRESENTATION OF SHOCK

• Altered mental status-

Restless, confusion, stupor, coma, agitation

• Patient may unconscious or semi-conscious

• Pallor

• Cold clammy skin. Warm in septic shock

• Increase sweating

• Pulse-Tachycardia, rapid weak thready pulse

⚫ Respiration-Tachypnia, slow and regular

• Blood pressure-low blood pressure Temperature may or may not be raised

Dehydration

Reduce urine output

DIAGNOSIS OF SHOCK

• History taking

• General and physical examination

• Vital sign assessment

LAB DIAGNOSIS

• CBC

• Biochemical test-serum electrolyte, ramdom blood sugar,s.creatinine

• ECG

• Chest x-ray

• Blood culture, urine R/M/E & C/S,sputum for gram

stain & C/S

Blood grouping & Cross matching

Cardiac enzyme

Arterial blood gas analysis

MANAGEMAENT OF SHOCK

• Admitted in intensive care unit

• Ensure ABC

Clear airway, adequate breathing, assessment of circulation-

pulse, BP, urine volume.

• Position of the patient

Trendelenburg or supine position to increase cerebral blood flow.

⚫ Oxygenation-High flow oxygen should be delivered. Establish IV access

Restore circulatory blood volume-blood in case of

bleeding,crystalioíd(n/s,ringer' s lactate)

• Vasoactive drugs

Dopamine with or with out dobutamine provide ionotropic support increasing

perfusion of the ischemic myocardium &all body tissue.

• Surgical intervention if needed.

⚫ Insulin therapy in case of hyperglycemia

• Treatment of underlying cause:

Broad spectrum antibiotic coverage in case of infection.

Cardiogenic shock-treatment according to cause such as MI or left ventricular

failure.

Hypovolumic shock-adrenalin I/m Hydrocortisone

• In acute adrenal insufficiency-Corticosteroid use as life saving drug.

• Activated protein-C can be use in severe sepsis.

PROGNOSIS OF SHOCK

• The prognosis varies with the origin of shock and its duration.

• 80%-90% of young with hypovolumic shock survive with appropiate

management.

• Cardiogenic shock associated with extensive myocardial infraction

mortality rate up to 75%

Septic shock-mortality rate up to 75%

•Haemorrhage:

1. may be defined as an escape of blood outside its containing vessel,

or

2. extravasation of blood from its containing vessels.

Classification/Types

A. According to Type of blood vessels:

1. Arterial

2. Venous
3. Capillary

B. A/C to onset/timing:

1. Primary

2. Reactionary

3. Secondary

C. According to Nature/Visibility:

1. Revealed haemorrhage and

2. Concealed haemorrhage

D. A/C to type of intervention:

1. Surgical Hge

2. Non-surgical Hge.

E. A/C to the Duration:

1. Acute Hge.

2. Chronic Hge.

THE TYPES OF BLEEDING

arterial bleeding

venous bleeding

capillary bleeding

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ARTERIES

VEINS

CAPILLARIES

• Spurting blood

• Pulsating flow

• Bright red color

• Steady, slow flow

• Slow, even flow

• Dark red color

Onset/Timing

A. Primary Hge: haemorrhage occurring immediately due to an injury (or

surgery).

Cause:

injury to vessels

May be arterial, venous or capillary. More common in surgery on

malignancies

B. Reactionary haemorrhage: Bleeding within 24 hours (usually 4-6 hrs) of

surgery.

Cause:

1. Slipping of ligature,

2. Dislodgement of clot or

3. Cessation of reflex vasospasm

Example of Reactionary Hge:

1. Thyroidectomy

2. Tonsillectomy

3. Prostatectomy

4. Haemorrhoidectomy

C. Secondary Hge: Hge occurs after 7-14 days of surgery.

Cause:

1. sloughing of vessel due to infection,

2. pressure necrosis,

3. Malignancy,

4. Presence of foreign body. Common after hemorrhoids surgery, GI surgery

& amputations.

According to Nature/Visibility:

A. External Haemorrhage or Revealed Hge:

Example:
1. soft tissue injuries

2. Bleeding from the limb vessels,

3. wound,

4. Nose(epistaxis)

5. Hemoptysis

6. Hematemesis

7. Malena.

Internal Haemorrhage or Concealed:

Internal or invisible bleed -

Causes:

1. Blunt or Penetrating trauma

2. May remain concealed as in ruptured spleen or liver.

Concealed hemorrhage may become revealed as in haemetemesis or

melaena in peptic ulcer bleed

• Example of internal Hge:

1. Haemocranium (Blood in side the cranium by trauma) i.e: EDH, SDH, ICH

2. Haemothorax (Blood in the thoracic cavity by blunt trauma)

3. Hemoperitoneum (blood in side the peritoneal cavity), liver, spleen or

mesenteric injury or rupture ectopic pregnancy.

4. Retroperitoneal Hge: Injury to kidney, rupture aortic aneurysm.

5. Fracture long bone: Blood collect inside the limh/ fomur fractural

Clinical Feature of Hge

• Depends upon 2 factor:

1. Amount of Blood loss.

2. Speed of Blood Loss.

Acute Blood Loss(internal bleeding/Concealed Hge)

1. Increasing Pallor

2. Increasing Pulse

3. Increasing restlessness
4. Deep respiration

5. Sign of Shock

Sign of Shock

1. Cold clammy skin

2. Tachycardia

3. Hypotension

4. Reduced Urine output

5. Collapse peripheral vein

6. Altered consciousness level

Feature of Chronic Blood Loss : Anemia

Monitoring of Hge(Acute):

1. Pulse Rate:

10% Blood Loss, No problem - Just Tachycardia 50% Blood Loss Pulse Absent.

Measure every 15/30 min Interval When Pt is Stable - Monitor 4 hourly.

2. Blood Pressure. Blood pressure is usually well maintained and only falls
after 30-40 per cent of circulating volume has been lost.

3. Urine Output.

Normal Urine output 1ml/kg/hr or 1ml/min Half than normal is Ok But less
than 30 ml/hr - Oliguria If blood loss > 50% - Anuria develop.

Control Of Hge

Control bleeding using these techniques:

A. Non Surgical Technique

1. Direct pressure ("pressure dressing") and Packing

2. Elevation

3. Pressure points (Brachial artery, Femoral artery)

4. Tourniquets Application

5. Adrenaline soaked gauze/pad

6. Warm mop/Hot mop.

B. Surgical:
1. Catch the bleeding point by artery forceps.

2. Ligation of bleeding vessels

3. Electro-cauterization.

4. Reapir(liver injry, kidney injury, great vessels).

5. Excision (soid organ where repair not possible i.e - spleen, kidney)

C. Endoscopic technique:

1. Sclerotherapy

2. Cauterization

3. Ligation

D. Modern technique:

1. Transarterial chemo- embolisation/Angioembolisation.

Others:

1. Gel foam/Gelatin sponge.

2. Spongiostant.

3. Muscle

4. Bone wax.

• How you will restore blood volume:

1. Blood Transfusion

2. Hemaccel(artificial Plasma solution)

3. I/V fluid(Hartman/Ringer's Lactate)

THE TYPES OF BLEEDING

arterial bleeding

venous bleeding

capilary tieeding

DIRECT PRESSURE:CAN BE APPLIED BY:

FIRST AIDER'S HAND.

DRESSING & FIRST AIDER'S HAND.

PRESSURE DRESSING.

PRESSURE TO BE APPLIED FOR 10 TO 30 MINUTES.

AFTER CONTROL, APPLY FIRM BANDAGE.

Don't remove dressing

INTRODUCTION:

Septicemia is a potentially life-threatening infection in which large amounts

of bacteria are present in the blood, It is commonly referred to as blood
poisoning.

Septicemia, sometimes referred to as a medical condition that is caused by

bacteria that is known as spectcemia or bacteremia. These bacteria affects
the bodily functions of the blood as it is responsible for the carrying of
oxygen, nutrients to your cells and it also carries waste and carbon dioxide.
The human blood is also responsible for carrying important antibodies this
makes it vulnerable to bacterial infections (pathogens) which get into the
bloodstream and spread the infection rapidly. This infection is usually called
Sepsis.

Site of infection

• Respiratory system

• Skin

• Gastrointestinal system
• Genitourinary system.

• It may coincide with very aggressive infections such as Meningitis.

Bacteria Involved

• Bacteria usually spill over from the primary infection site into the blood and
are carried throughout the body thereby spreading infection to various
systems of the body. Bacteria such as:

* E. coli

*Streptococcus pneumoniae

→ Salmonella

* Haemophilus influenzae

* Type B, Listeria monocytogenes

INTRODUCTION:

Septicemia is a potentially life-threatening infection in which large amounts

of bacteria are present in the blood, It is commonly referred to as blood
poisoning.

Septicemia, sometimes referred to as a medical condition that is caused by

bacteria that is known as spectcemia or bacteremia. These bacteria affects
the bodily functions of the blood as it is responsible for the carrying of
oxygen, nutrients to your cells and it also carries waste and carbon dioxide.
The human blood is also responsible for carrying important antibodies this
makes it vulnerable to bacterial infections (pathogens) which get into the
bloodstream and spread the infection rapidly. This infection is usually called
Sepsis.

Site of infection

• Respiratory system

• Skin

• Gastrointestinal system

• Genitourinary system.

• It may coincide with very aggressive infections such as Meningitis.

Bacteria Involved

• Bacteria usually spill over from the primary infection site into the blood and
are carried throughout the body thereby spreading infection to various
systems of the body. Bacteria such as:

* E. coli

*Streptococcus pneumoniae

→ Salmonella
* Haemophilus influenzae

* Type B, Listeria monocytogenes

DIAGNOSIS OF SEPTICEMIA

• Physical Examination

• Low blood pressure

• Low body temperature

• Microbiogical analysis

• Blood culture

• Urine culture

• Blood Tests

• Arterial Blood Gas

• Platelet count CBc

TREATMENT:
• Hospitalization

• Antibiotics: Clindamycin Ofloxacin Ampicillin Amoxycllin..etc.

• Oxygen Therapy

• Intensive care Supportive therapy

• Fluids

• Homeopathic medicines- Carbolic acid, Arnica ..etc.

PREVENTION:

• Treating wounds

• Treating infections

• Regular dental checkup

WASTES

WASTES

"Something which is not put into proper usage at given time". a

Wastes
Solid waste

Liquid Waste

Gaseous Waste

Household waste

Industrial waste

Biomedical waste or hospital waste

BIO-MEDICAL WASTE: -

Any waste which is generated during the diagnosis, treatment or

immunization of human beings or animals or in research activities pertaining
thereto or in the production or testing of biological.

BIOHAZARD

CAUSES

Improper:-

✓ Packaging

✓ Segregation
✓ Treatment and disposal

of waste. Biomedical

CLASSIFICATION OF BIOMEDICAL WASTE:

INFECTIOUS WASTE.

PATHOLOGICAL WASTE.

SHARPS.

PHARMACEUTIC AL WASTE.

WASTES WITH HIGH CONTENT OF HEAVY METALS.

GENOTOXIC WASTE.

PRESSURIZED CONTAINERS

CHEMICAL WASTE.

RADIOACTIVE WASTE

CLASSIFICATION OF BIOMEDICAL WASTE:

1. INFECTIOUS WASTE:
Infectious suspected to waste contain pathogens (bacteria, viruses, fungi)
parasites, or in sufficient quantity to cause diseases in susceptible hosts.

CAUTION

INFECTIOUS WASTE NOTIFY PUBLIC HEALTH AUTHORITY IN CASE OF DAMAGE

OR LEAK

This category includes:-

Cultures and stocks of infectious agents laboratory work. from

Waste from surgery on patients with infectious diconco

Classification continue...

2.PATHOLOGICAL WASTE:

It consists of tissues, organs, body parts, human fetuses, and animal

carcasses, blood, and body fluids

3. SHARPS:

These are the items that could cause cuts or puncture wounds, including;

✓ Needles,

✓ Scalpel and other blades,

✓ Knives,

✓ Infusion sets,

Saws,

Broken glass, and nails.

Classification continue...

4.PHARMACEUTICAL WASTE:

It includes expired, unused, spilt, and contaminated

✓ Pharmaceutical products,

✓ Drugs,

✓ Vaccines, and sera

5. GENOTOXIC WASTE:

Genotoxic waste is highly hazardous and may have;

✓ Mutagenic,

✓ Teratogenic, or
✓ Carcinogenic propertie

It raises serious safety problems, both inside hospitals and after disposal,
and should be given special attention.

HOSPITAl

• It includes certain cytostatic drugs, vomit, urine, or feces from patients

treated with cytostatic drugs, chemicals, and radioactive material.

Classification continue...

6. CHEMICAL WASTE:

It consists of discarded ✓Solid,

✓ Liquid, and

✓ Gaseous chemicals

Chemical waste may be hazardous or nonhazardous.

It is considered to be hazardous if it has at least one of the following

properties:

✓ Toxic,

✓ Corrosive (acids of pH < 2 and bases of pH> 12)

✓ Flammable,

✓ Reactive

✓ Genotoxic

7. WASTES WITH HIGH CONTENT OF HEAVY METALS:

It represents a subcategory of hazardous chemical waste, and is usually

highly toxic.

It includes

✓ Batteries,

✓ Broken thermometer,

✔ Blood-pressure gauges.

BROKEN MERCURY THERMOMETERS

Classification continue...

8. PRESSURIZED CONTAINERS:
Many types of gas are used in health care, and are often stored in
pressurized cylinders, cartridges, and aerosol cans.

Most common gases used in health care includes:

✓ Anesthetic gases

✓ Ethylene oxide

✓ Oxygen

Compressed air

SOURCES OF BIO-MEDICAL WASTE

HOSPITALS, HEALTH CARE CENTERS

BLOOD BANKS

BIO TECHNOLOGICAL INSTITUTION

EFFECTS OF BIOMEDICAL WASTE:

The management improper of biomedical waste causes serious

environmental problems in terms of

✓ Air,
✓ Water and

✓ Land pollution.

Effects continue...

1. AIR POLLUTION:

Air pollution can be caused in both indoors and outdoors.

• Biomedical waste that generates air pollution is of three types-

• Biological, Chemical and Radioactive.

Air pollution continue...

A. Indoor air pollution:-

Hospital Acquired Infections (Nosocomial infection).

Indoor air pollution can caused due to:

• Poor ventilation

The paints, carpet, furniture, equipment's, etc., used in the rooms.

Use of chemicals, disinfectants, fumigants etc

. LAND POLLUTION:

Open dumping of biomedical waste is the greatest cause for land

pollution.

Soil pollution from bio-medical waste is caused due to infectious

waste, chemicals. discarded medicines,

Heavy metals such as cadmium, lead, mercury, etc., which are

present in the waste will get absorbed by plants and can then enter
the food chain.

Methods of disposal of bio-medical

waste and their segregation

WASTE CATEGORY

TYPE OF WASTE

TREATMENT ANE DISPOSAL OPTION

Category No. 1

Human Anatomical Waste (Human tissues, organs, body parts)

Animal Waste
Category No. 2

(Animal tissues, organs, body parts, carcasses, bleeding parts, fluid,

blood and experimental animals used in research, waste generated
by veterinary hospitals and colleges, discharge from hospitals,)

Incineration@/ deep burial

Category No. 3

Microbiology & Biotechnology Waste (Wastes from laboratory

cultures, stocks or specimen of live microorganisms, human and
animal cell cultures used in research and infectious agents from
research and industrial laboratories, wastes from production of
biological, toxins and devices used for transfer of cultures)

Local autoclaving/ microwaving/ incineration@

Category No.

4 Waste Sharps (Needles, syringes, scalpels, blades, glass, etc. that

may cause puncture and cuts. This includes both used and unused
sharps)

Disinfecting (chemical treatment@@/autoclaving/ microwaving and

mutilation / shredding

Category No.
5 Discarded Medicine and Cytotoxic drugs (Wastes comprising of
outdated, contaminated and discarded medicines)

Incineration@ / destruction and drugs disposal in secured landfill

Category No. 6

Soiled Waste (Items contaminated with body fluids including cotton,

dressings, soiled plaster casts, lines, bedding and other materials
contaminated with blood.)

Incineration@/autoclaving/ microwaving

Category No. 7

Solid Waste (Waste generated from disposable items other than the
waste sharps such as tubing, catheters, intravenous sets, etc.)

Disinfecting by chemical treatment@@/autoclaving/ microwaving

and mutilation/ shredding

Category No. 8

Liquid Waste (Waste generated from the laboratory and washing,

cleaning, housekeeping and disinfecting activities)

Download now

Disinfecting by chemical treatment@@ and discharge into drains

Category No. 9

Incineration Ash (Ash from incineration of any biomedical waste)

Disposal in municipal landfill

Chemical Waste (Chemicals used in production of biological,

chemicals used in disinfecting, as insecticides, etc.)

Chemical treatment @@ and discharge into drains for liquids and

secured landfill for solids.

STEPS IN THE MANAGEMENT OF BIOMEDICAL WASTE:-

Survey of waste generated.

Treatment of waste.

Segregation of hospital waste.

Transportation of waste.

Storage of waste.(Not beyond 48 hrs.)

Collection & Categorization of waste.

COLOR CODING FOR SEGREGATION OF BIOMEDICAL WASTE

Vallow

Human & Animal anatomical waste/ Micro-biology waste and soiled

cotton/dressings/linen/beddings etc.

Incineration/Deep burial

Tubing's, Catheters, IV sets.

Autoclaving / Microwaving/ Chemical treatment

Blue/ White

Waste sharps (Needles, Syringes, Scalpels, blades etc. )

Autoclaving/Microwaving/ Chemical treatment & Destruction/

Shredding

Black

Discarded medicines/cytotoxic drugs, Incineration ash, Chemical

waste.

Disposal in secured landfill