In severe liver injuries (class ≥III), or those with hemodynamic instability, surgical correction is generally necessary. In these severe injuries a hepatopancreatobiliary surgeon may be utilized rather than a trauma surgeon given their expertise with the organ and generally yields better outcomes. Surgical techniques such as perihepatic packing or the use of the Pringle manoeuvre can be used to control hemorrhage. Temporary control of the hemorrhage can be accomplished through direct manual pressure to the wound site. In these severe cases it is important to prevent the progression of the trauma triad of death, which often requires the utilization of damage control surgery. The common cause of death while operating is exsanguination caused by profuse loss of blood volume. Rarely, surgery entails the use of liver resection, which removes the source of the bleeding and necrotic tissue. The drastic nature of this procedure means it can only be used in hemodynamically stable patients. Another rare procedure would be liver transplantation which is typically impractical due to the logistics of finding a proper organ donor in a timely fashion.

Kousnetzoff aluminium needle is used to suture liver tear. Co-opting sutures are placed perpendicular to already placed parallel mattress sutures on either side of lacerations. Other methods are tractotomy and mesh hepatorrhaphy.

Exsanguination is a relatively uncommon cause of death in human beings. Traumatic injury can cause exsanguination if bleeding is not promptly controlled, and is the most common cause of death in military combat. Non-combat causes can include gunshot or stab wounds; motor vehicle crash injuries; suicide by severing arteries, typically those in the wrists; and partial or total limb amputation, such as via accidental contact with a circular or chain saw, or becoming entangled in operating machinery.

Patients can also develop catastrophic internal hemorrhages, such as from a bleeding peptic ulcer, postpartum bleeding or splenic hemorrhage, which can cause exsanguination without any external signs of distress. Another cause of exsanguination in the medical field is that of aneurysms. If a dissecting aortic aneurysm ruptures through the adventitia, massive hemorrhage and exsanguination can result in a matter of minutes.

Blunt force trauma to the liver, kidneys, and spleen can cause severe internal bleeding as well, though the abdominal cavity usually becomes visibly darkened as if bruised. Similarly, trauma to the lungs can cause bleeding out, though without medical attention, blood can fill the lungs causing the effect of drowning, or in the pleura causing suffocation, well before exsanguination would occur. In addition, serious trauma can cause tearing of major blood vessels without external trauma indicative of the damage.

Alcoholics and others with liver disease can also suffer from exsanguination. Thin-walled, normally low pressure dilated veins just below the lower esophageal mucosa called esophageal varices can become enlarged in conditions with portal hypertension. These may begin to bleed, which with the high pressure in the portal system can be fatal. The often causative impaired liver function also reduces the availability of clotting factors (many of which are made in the liver), making any rupture in vessels more likely to cause a fatal loss of blood.

Exsanguination is the process of blood loss, to a degree sufficient to cause death. One does not have to lose all of one's blood to cause death. Depending upon the age, health, and fitness level of the individual, people can die from losing half to two-thirds of their blood; a loss of roughly one-third of the blood volume is considered very serious. Even a single deep cut can warrant suturing and hospitalization, especially if trauma, a vein or artery, or another comorbidity is involved. It is most commonly known as "bleeding to death" or colloquially as "bleeding out". The word itself originated from Latin: "ex" ("out of") and "sanguis" ("blood").

The initial management of liver trauma generally follows the same procedures for all traumas with a focus on maintaining airway, breathing, and circulation. A physical examination is a corner stone of the assessment of which there are various non-invasive means of diagnostic tools that can be utilized. An invasive diagnostic peritoneal lavage can also be used to diagnose and classify the extent of the damage. A large majority of liver injuries are minor and require only observation. Generally if there is estimated to be less than 300mL of free floating fluid, no injury to surrounding organs, and no need for blood transfusion, there is a low risk of complication from nonoperative management. In special cases where there is a higher risk with surgery, such as in the elderly, nonoperative management would include the infusion of packed red blood cells in an intensive care unit. Typically hepatic injuries resulting from stab wounds cause little damage unless a vital part of the liver is injured such as the hepatic portal vein, with gunshot wounds, the damage is worse.

Emergency oxygen should be immediately employed to increase the efficiency of the patient's remaining blood supply. This intervention can be life-saving.

The use of intravenous fluids (IVs) may help compensate for lost fluid volume, but IV fluids cannot carry oxygen in the way that blood can; however, blood substitutes are being developed which can. Infusion of colloid or crystalloid IV fluids will also dilute clotting factors within the blood, increasing the risk of bleeding. It is current best practice to allow permissive hypotension in patients suffering from hypovolemic shock, both to ensure clotting factors are not overly diluted and also to stop blood pressure being artificially raised to a point where it "blows off" clots that have formed.

Treatment of TBI varies based on the location and severity of injury and whether the patient is stable or having trouble breathing, but ensuring that the airway is patent so that the patient can breathe is always of paramount importance. Ensuring an open airway and adequate ventilation may be difficult in people with TBI. Intubation, one method to secure the airway, may be used to bypass a disruption in the airway in order to send air to the lungs. If necessary, a tube can be placed into the uninjured bronchus, and a single lung can be ventilated. If there is a penetrating injury to the neck through which air is escaping, the trachea may be intubated through the wound. Multiple unsuccessful attempts at conventional (direct) laryngoscopy may threaten the airway, so alternative techniques to visualize the airway, such as fiberoptic or video laryngoscopy, may be employed to facilitate tracheal intubation. If the upper trachea is injured, an incision can be made in the trachea (tracheotomy) or the cricothyroid membrane (cricothyrotomy, or cricothyroidotomy) in order to ensure an open airway. However, cricothyrotomy may not be useful if the trachea is lacerated below the site of the artificial airway. Tracheotomy is used sparingly because it can cause complications such as infections and narrowing of the trachea and larynx. When it is impossible to establish a sufficient airway, or when complicated surgery must be performed, cardiopulmonary bypass may be used—blood is pumped out of the body, oxygenated by a machine, and pumped back in. If a pneumothorax occurs, a chest tube may be inserted into the pleural cavity to remove the air.

People with TBI are provided with supplemental oxygen and may need mechanical ventilation. Employment of certain measures such as Positive end-expiratory pressure (PEEP) and ventilation at higher-than-normal pressures may be helpful in maintaining adequate oxygenation. However, such measures can also increase leakage of air through a tear, and can stress the sutures in a tear that has been surgically repaired; therefore the lowest possible airway pressures that still maintain oxygenation are typically used. Mechanical ventilation can also cause pulmonary barotrauma when high pressure is required to ventilate the lungs. Techniques such as pulmonary toilet (removal of secretions), fluid management, and treatment of pneumonia are employed to improve pulmonary compliance (the elasticity of the lungs).

While TBI may be managed without surgery, surgical repair of the tear is considered standard in the treatment of most TBI. It is required if a tear interferes with ventilation; if mediastinitis (inflammation of the tissues in the mid-chest) occurs; or if subcutaneous or mediastinal emphysema progresses rapidly; or if air leak or large pneumothorax is persistent despite chest tube placement. Other indications for surgery are a tear more than one third the circumference of the airway, tears with loss of tissue, and a need for positive pressure ventilation. Damaged tissue around a rupture (e.g. torn or scarred tissue) may be removed in order to obtain clean edges that can be surgically repaired. Debridement of damaged tissue can shorten the trachea by as much as 50%. Repair of extensive tears can include sewing a flap of tissue taken from the membranes surrounding the heart or lungs (the pericardium and pleura, respectively) over the sutures to protect them. When lung tissue is destroyed as a result of TBI complications, pneumonectomy or lobectomy (removal of a lung or of one lobe, respectively) may be required. Pneumonectomy is avoided whenever possible due to the high rate of death associated with the procedure. Surgery to repair a tear in the tracheobronchial tree can be successful even when it is performed months after the trauma, as can occur if the diagnosis of TBI is delayed. When airway stenosis results after delayed diagnosis, surgery is similar to that performed after early diagnosis: the stenotic section is removed and the cut airway is repaired.

A gunshot wound (GSW) is a form of physical trauma sustained from the discharge of arms or munitions. The most common forms of ballistic trauma stem from firearms used in armed conflicts, civilian sporting, recreational pursuits and criminal activity. Ballistic trauma can be fatal or cause long-term consequences.

Vehicle occupants who wear seat belts have a lower incidence of TBI after a motor vehicle accident. However, if the strap is situated across the front of the neck (instead of the chest), this increases the risk of tracheal injury. Design of medical instruments can be modified to prevent iatrogenic TBI, and medical practitioners can use techniques that reduce the risk of injury with procedures such as tracheotomy.

Fluid replacement is beneficial in hypovolemia of stage 2, and is necessary in stage 3 and 4. See also the discussion of shock and the importance of treating reversible shock while it can still be countered.

For a patient presenting with hypovolemic shock in hospital the following investigations would be carried out:

- Blood tests: U+Es/Chem7, full blood count, glucose, blood type and screen

- Central venous catheter or blood pressure

- Arterial line or arterial blood gases

- Urine output measurements (via urinary catheter)

- Blood pressure

- SpO2 Oxygen saturations

The following interventions would be carried out:

- IV access

- Oxygen as required

- Surgical repair at sites of hemorrhage

- Inotrope therapy (Dopamine, Noradrenaline) which increase the contractility of the heart muscle

- Fresh frozen plasma or whole blood

Vasopressors (like Norepinephrine, Dobutamine) should generally be avoided, as they may result in further tissue ischemia and don't correct the primary problem. Fluids are the preferred choice of therapy.

The degree of tissue disruption caused by a projectile is related to the size of the temporary versus permanent cavity it creates as it passes through tissue. The extent of cavitation, in turn, is related to the following characteristics of the projectile:

- Kinetic energy: KE = 1/2"mv" (where "m" is mass and "v" is velocity). This helps to explain why wounds produced by missiles of higher mass and/or higher velocity produce greater tissue disruption than missiles of lower mass and velocity.

- Impulse: IMP = "mv". The impulse is working in a couple with kinetic energy, featuring the same characteristics

- Yaw

- Deformation

- Fragmentation

The immediate damaging effect of a gunshot wound is typically severe bleeding, and with it the potential for hypovolemic shock, a condition characterized by inadequate delivery of oxygen to vital organs. In the case of traumatic hypovolemic shock, this failure of adequate oxygen delivery is due to blood loss, as blood is the means of delivering oxygen to the body's constituent parts. Devastating effects can result when a bullet strikes a vital organ such as the heart or lungs, or damages a component of the central nervous system such as the spine or brain.

Common causes of death following gunshot injury include exsanguination, hypoxia caused by pneumothorax, catastrophic injury to the heart and larger blood vessels, and damage to the brain or central nervous system. Additionally, gunshot wounds typically involve a large degree of nearby tissue disruption and destruction due to the physical effects of the projectile. Non-fatal gunshot wounds frequently have severe and long-lasting effects, typically some form of major disfigurement and/or permanent disability.

Gunshot injuries can vary widely from case to case since the location of the injury can be in any part of the body, with wide variations in entry point. Also, the path and possible fragmentation of the bullet within the body is unpredictable. The study of the dynamics of bullets in gunshot injuries is called terminal ballistics.

As a rule, all gunshot wounds are considered medical emergencies that require immediate treatment. Hospitals are generally required to report all gunshot wounds to police.

It is recommended that women with vasa previa should deliver through elective cesarean prior to rupture of the membranes. Given the timing of membrane rupture is difficult to predict, elective cesarean delivery at 35–36 weeks is recommended. This gestational age gives a reasonable balance between the risk of death and that of prematurity. Several authorities have recommended hospital admission about 32 weeks. This is to give the patient proximity to the operating room for emergency delivery should the membranes rupture. Because these patients are at risk for preterm delivery, it is recommended that steroids should be given to promote fetal lung maturation. When bleeding occurs, the patient goes into labor, or if the membranes rupture, immediate treatment with an emergency caesarean delivery is usually indicated.

Vasa praevia, also spelled vasa previa, is a condition in which babies' blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue.

Risk factors include in vitro fertilization.

Vasa praevia occurs in about 0.6 per 1000 pregnancies. The term "vasa previa" is derived from the Latin; "vasa" means vessels and "previa" comes from "pre" meaning "before" and "via" meaning "way". In other words, vessels lie before the baby in the birth canal and in the way.