A 12-year-old girl, restrained rear-seat passenger in a car crash 6 hours ago, now complains of nausea. BP 80/40, P 116, R 20. What should you suspect?

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In children, a collapse into hemorrhagic shock after blunt abdominal trauma can be delayed, so a six-hour gap with new symptoms like nausea plus falling blood pressure points to intra-abdominal bleeding from an organ injury. The low blood pressure (80/40) with tachycardia suggests volume loss from blood loss, and in the context of a car crash, the abdomen is a common source of that loss due to blunt injury to the spleen, liver, or mesentery. The nausea fits with visceral irritation and evolving shock. Other injuries might produce different signs—for example, head or spinal injuries would more likely show neuro deficits or altered mental status, and a fractured femur typically causes localized pain and swelling with blood loss that is less likely to cause profound hypotension in the absence of other injuries. So the most likely concern is abdominal injury with internal bleeding.