Forty-three trauma patients underwent tracheostomy (TRACH) and percutaneous endoscopic gastrostomy (PEG) over 21 months. Thirty-one patients had a head injury with Abbreviated Injury Scale > or = 3 associated with multi-trauma. This study was undertaken to analyze demographic and outcome variables with respect to timing of TRACH/PEG in this population. Patients were divided into EARLY (< or = 7 days) and LATE (> 7 days) groups and were analyzed for admission Glasgow Coma Scale, Apache II, Injury Severity Score, and [(A-a)DO2] at time of TRACH/PEG. Outcome variables were ICU length of stay (LOS), hospital LOS, days of mechanical ventilation (MV) post-TRACH/PEG, complications, and mortality. Esophagogastroduodenoscopy findings with PEG and days to full enteral nutrition were recorded. All demographic variables were statistically similar between the EARLY and LATE groups. The EARLY group had shorter hospital LOS (P < 0.05), total Intensive Care Unit LOS (P < 0.05), ICU LOS post-TRACH/PEG (P < 0.05), and fewer days of MV post-TRACH/PEG (P < 0.05). There were no procedure-related complications of TRACH/PEG in either group. Full Esophagogastroduodenoscopy performed at the time of PEG had a high diagnostic yield in both groups. We conclude that TRACH/PEG performed within the first 7 days of injury in the head trauma patient is the procedure of choice for long-term airway protection, mechanical ventilation, and enteral nutrition. Combined use of these procedures reduces ICU and hospital LOS and shortens the course of MV.