Objective: Death from trauma is a major problem for the health system. The determination of preventable deaths is a valuable indicator of quality and efficiency in the management of trauma patients. The purpose of our study was to investigate the cause of preventable death in pre-hospital settings in the city of Tabriz. Materials and Methods:In a cross-sectional study from 2013 to 2014 in Tabriz, all traumatic patients who died at the scene of trauma or during transport and before reaching the hospital were referred to forensics for autopsy studies. For all deaths, data on demographics, mechanism and type of injury, place of death, mode of transportation, injury to the central nervous system (CNS) and results of necropsy were recorded. Preventability of death was defined upon examination of the necropsy report.Results: In this study, 160 pre-hospital deaths were studied. The commonest mechanism of injury was a vehicular traffic accident (83.8%), and blunt trauma in 98.8% was the commonest type of injury. In total, 80.6% of the deaths were at the scene of trauma and 18.8% on arrival to the hospital. CNS injury was recorded in 71.9% of the cases. The commonest cause of death from the necropsy report was CNS injury (60.6%), exsanguination or breathing problems (28.1%), and CNS injury with exsanguination or breathing problems (11.2%). In this study, death was possibly preventable in 25.6% of the cases, and 21.9% of the deaths were definitively preventable. Conclusion:Many deaths occurred at the scene of trauma, and traffic accidents are the main mechanism of injury. A high percentage of deaths as seen in the autopsy had CNS injuries, and this was the main cause of death. The high rate of preventable death in the present study compared to that in similar studies in other countries is a significant finding.

Worldwide trauma is currently the sixth leading cause of death, according to 10% of mortalities (1,2). Injury impact and the death from trauma are more common in males than females. People aged between 15 and 45 years include about half of the trauma deaths (3). Citizens of low-and middle-income countries (LMICs) account for 89% of all deaths from trauma worldwide. This is particularly because of hospitals' lack of facilities, equipments, and peripheral care systems (4,5). During last year since the 20th of March 2013 until the 20th of March 2014, 27 740 traumatic patients were admitted to Iran's North West Trauma Center (Emam Reza hospital) in which 105 patients were expired in emergency, surgery, and neurosurgery departments. This included 11 female patients (10%) and 94 male patients (90%) (Figure 1). According to previous studies, motor vehicle accidents are the most common reason of multitrauma. Researchers highlight that in developing countries, trauma is the leading cause of death for young people (6). In our study, the reports show that the causes of injury that led to death in 71 patients were motor vehicle crash, in 25 patients falling from a high altitude, one patient because of pedestrian motor vehicle accident, and 8 patients because of fighting (Figure 2). Seventy-five patients in morning shifts (8 am to 8 pm) and 30 patients in night shifts (8 pm to 8 am) were admitted. Approximately about 30 patients in spring, 34 patients in summer, 25 patients in fall and 18 patients in winter experienced traumatic injury leading to death.

Emergencies, Rush, OutcomesEmergency department overcrowding can affect the process of seeking help for critically ill patients in the emergency department. The aim of this study was to investigate the relationship between crowding and clinical outcome of referred critical patients from other hospitals.This was a retrospective cross-sectional study performed on 583 critically ill patients (triage levels one and two) referred to the emergency department of Imam Reza Hospital, Tabriz, Iran, between 22 September 2016 and 22 March 2017. Clinical outcome was considered as death rate and the crowd was measured in terms of the number of patients per hour. Statistical analysis was performed using SPSS.The mean ± standard deviation (SD) of age was 49.5 ± 25.0 years old with 56.4% frequency of men and 43.2% women. About 53.5% of people were referred during peak hour. Evaluating the final outcome, 21.6% of patients died in the emergency department, while 41.5% and 36.9% were cured and discharged or hospitalized respectively. The mean ± SD duration of staying in the emergency department was 239.6 ± 233.0 minutes. A significant percentage of death was during the peak hour of emergency referrals. The final outcome got worse with an increased number of patients admitted to the emergency room.Crowding in the emergency department deteriorated the treatment process of patients with a critical condition. Thus, the final outcome of the disease or the mortality rate of patients admitted to emergency worsened. Constructive measures to reduce the crowding in the emergency department should be considered.Citation: Ala A, Shams-Vahdati S, Fahimi R. The relationship between emergency department crowding and outcome of referred critical patients from other hospitals.

Stroke, a leading cause of neurological disability in the world, is the third major reason for mortality after cancer and heart diseases. It is an epidemic emerging worldwide, especially in the low and middle-income countries. Most of the patients survived from stroke are not treated completely and have a life with disability and complications. Therefore, it is necessary that medical students be trained and educate in a standardized manner through focused lectures, interactive workshops, and bedside teaching sessions so that they can deal with these patients and manage potentially disabling neurological emergencies such as stroke correctly.

Case Presentations: A 63-year-old female with no significant prior trauma and relevant past medical history presented with a 2month history of severe, persistent, gradually worsening, sharp and non-radiating pain over her left distal fibula. Physical examination revealed extreme tenderness to palpation over the lateral distal fibula. There was soft tissue prominence over the mid to lower third of the fibula. Results: Left lower leg radiographs depicted two ill-defined osteolytic destructive lesions measuring 29 and 37 mm in length in the fibular diaphysis. A pathologic fracture was present through the distal lesion. A laboratory test, including serum protein electrophoresis, alkaline phosphatase and basic metabolic profile, was ordered to evaluate for multiple myeloma. CT scans of the chest and abdomen were obtained to evaluate for primary malignancy or any evidence of metastatic disease. The results of these tests were unremarkable. Image-guided biopsy of the lesions was performed and revealed epithelioid hemangioma (EH). The patient was initially managed with a walker boot. At the 2-month follow-up, an additional third smaller lesion was detected along with an interval increase in size of the two previously seen lesions. The patient proceed with preoperative embolization followed by surgical curettage and open reduction and internal fixation. Angiogram was done and tumor feeding artery was identified but tumor embolization was unsuccessful. The patient underwent fibular bone lesion curettage, PRO-DENSE bone grafting and open reduction and internal fixation with the left fibular diaphyseal plate. Radiographs revealed continued healing with bone graft incorporation at 1.5-, 3-and 7-month follow-ups. The patient was permitted to return to all activities without restriction 1.5 months after the surgery. Conclusions: EH is an uncommon, slow-growing vascular tumor that generally presents on the skin and the subcutaneous soft tissues of the head, with osseous EHs being rare. Although osseous EHs can present as multifocal lesions, the majority of bony EHs are solitary and arise in the diaphysis or metaphysis of long tubular bones, with a predilection for the lower extremity. Radiographically, EH may present as well-defined lytic lesions with sclerotic margins or mixed lytic and sclerotic lesions. These lesions are often located eccentrically and may demonstrate a disrupted or intact cortex. This is an abstract presented in the 33rd Iranian congress of radiology (ICR) and the 15th congress of Iranian radiographic science association (IRSA).