BackgroundAmerican Society for Parenteral and Enteral Nutrition (ASPEN) guidelines recommend gastrostomy for patients suspected to require enteral access device for 4–6 weeks. Our hypothesis was that traumatic brain injury (TBI) patients undergoing synchronous tracheostomy/gastrostomy (SYNC) compared to tracheostomy first (DELAY) have shorter length of stay (LOS) but higher rates of unnecessary gastrostomy. MethodsRetrospective review of TBI patients requiring tracheostomy in 2017–2022 at a Level 1 trauma center was conducted. SYNC and DELAY patients were compared, and CoxPH analysis was performed for LOS. Results394 patients were included [mean age: 42 (SD:18); mortality: 9 %]. The DELAY group had longer LOS (39 vs 32 days, p < 0.001). There was no significant difference in unnecessary gastrostomy rate between groups (p = 0.1331). In adjusted hazard analysis, SYNC predicted shorter LOS (HR:1.54; 95 % CI:1.20–1.98, p < 0.001). ConclusionsSynchronous gastrostomy was associated with shorter length of stay and similar rates of unnecessary gastrostomy in TBI patients.