Traumatic rupture of the aorta--critical decisions for trauma surgeons. The diagnosis and initial stabilization of patients with traumatic rupture of the aorta (TRA) is performed by trauma surgeons. The resuscitations of 54 TRA patients at a Level I trauma center are reviewed. Although the survival of patients who underwent attempted repair was good (75%), 21/27 (78%) deaths occurred during phases of treatment controlled by a trauma surgeon. The techniques and sequencing of resuscitation can affect outcome. Pneumatic antishock garments were not beneficial in the prehospital setting for patients with TRA. In fact, PASG were on and inflated in all patients who presented in cardiac arrest. Awake, unanesthetized intubation caused fatal aortic rupture in three patients. Pharmacologic control of blood pressure during intubation is necessary. The amount of fluid, blood transfusion, and changes in blood pressure secondary to therapy did not statistically affect outcome. The average time from arrival in the ER to angiogram was 64.7 minutes. The average time ER to operating room was 159.7 minutes. Seven cases of TRA had delayed diagnosis usually for a misinterpreted CXR (5/7). Delay in diagnosis did not directly contribute to any deaths. Associated abdominal injuries are a common cause of preventable deaths. Fourteen patients with combined abdominal injuries and TRA were identified. Four of six deaths occurred with potentially reparable injuries. Operative and diagnostic sequences must be adjusted to allow rapid control of all potentially fatal injuries. 