A 26-year-old male presented with a laceration to the left lip after being struck with a fist. He had a history of Crohn’s disease, for which he took mesalamine, but was otherwise healthy. The patient was brought by ambulance to the emergency department and noted to have a complex laceration spanning from the left angle of the mouth to approximately 3 cm within the buccal mucosa. Moderate bleeding and swelling were noted.
After establishing that the patient’s injuries were limited to the laceration, the repair began. There was copious bleeding that appeared to be arterial during the procedure, and 15 absorbable and five nonabsorbable simple sutures were placed to achieve hemostasis. The patient was observed and had no signs of rebleeding and was discharged on prophylactic antibiotics and instructions to return in 48 hours for a wound check. The patient’s wound check at 3 days postprocedure and suture removal at 6 days postprocedure were uneventful, as the patient had only minimal swelling and no signs of infection or bleeding.
At 10 days postinjury, the patient presented with bleeding from the site of the laceration on the buccal mucosa. The bleeding appeared to be arterial in nature. The wound was repaired with four absorbable sutures and hemostasis was achieved.
At 37 days postinjury, the patient returned with recurrent bleeding from the wound site, without any history of reinjury (Figure 1). Within the upper lip adjacent to the location of the laceration was a pulsatile nodule.
The emergency physician performed a bedside ultrasound (Zonare Medical Systems, Inc., Mountain View, CA) utilizing a high-frequency L14-5sp linear array probe at 12 MHz (Figure 2 and Video Clip S1, available as supporting information in the online version of this paper) and noted an area of blood flow consistent with aneurysm or pseudoaneurysm of the superior labial artery. The oromaxillofacial surgeon was consulted, and the patient was scheduled for outpatient surgery, in which the labial artery was ligated in the operating room.
Aneurysms can be either true (often caused by atherosclerosis and involving all three components of the arterial wall) or false (often caused by trauma, bacterial, or mycotic infection), and aneurysms of the superior labial artery are particularly rare.1,2 Ultrasonography has been utilized to evaluate congenital superior labial artery abnormalities.3 This case demonstrates a rare complication of a common emergency department procedure and a novel approach to its diagnosis. The diagnosis was made quickly and noninvasively by emergency physician bedside ultrasound.