A 12-year-old female was a restrained rear-seat passenger in a car crash 6 hours earlier. She now complains of nausea. Vital signs are BP 80/40, P 116, R 20. What should you suspect?

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Blunt trauma can produce delayed internal bleeding that leads to shock. In children, perfusion can appear preserved until substantial blood loss has occurred, so tachycardia is often the first sign of deterioration and hypotension is a late, worrisome finding. Six hours after the crash, with a low blood pressure (80/40) and a heart rate of 116, nausea fits with intra-abdominal irritation from internal hemorrhage. The most likely source is abdominal bleeding from injury to an internal organ such as a spleen or liver, causing hypovolemic shock.

Head injury would more likely present with altered mental status or focal neurologic findings rather than this pattern of shock. Spinal injury could cause neuro deficits but not typically isolated hypotension with tachycardia and nausea. Pelvic fracture can cause heavy bleeding, but without pelvic signs or deformity described, abdominal bleeding remains the best fit given the mechanism and the delayed presentation after blunt trauma.