A Prospective, Randomized Trial of Early Versus Late Tracheostomy in Trauma Patients With Severe Brain Injury

Inclusion Criteria: * 18 years of age or older * TBI defined as penetrating or blunt brain injury including 1)subarachnoid hemorrhage, 2)subdural hemorrhage, 3) epidural hemorrhage, 4)brain contusion, 5)diffuse axonal injury * mechanically ventilated by endotracheal intubation * projected to need ventilation support for more than 14 days according to: GCS measured in field less than or equal to 8 and a GCS on day 3 which remains less than or equal to 8 * informed consent obtained from patient or legal representative Exclusion Criteria: * less than 18 years of age * projected to need ventilation support for less than 14 days * anatomical deformity of the neck, including thyromegaly and cervical tumors * previous tracheostomy * uncontrolled coagulopathy * existence of platelet count less than 50,000/mm2 * anti-platelet agents * clinical evidence of ongoing infection at the proposed tracheostomy site as per physician * mechanical ventilation with a positive end-expiratory pressure greater than 12 cm H20 * intubated more than 72 hours * patient has undergone cricothyroidotomy * cricoid cartilage, trachea, or sternal notch not palpable with neck in position