Autopsy studies reveal that 90 percent of patients with traumatic rupture of the thoracic aorta (TRTA) die at the scene of the accident and 25 percent of those reaching the hospital do not survive their injuries. Treatment priorities in patients with TRTA and associated life-threatening head and intra-abdominal injuries have not been adequately studied. The authors reviewed their experience with 57 consecutive patients sustaining TRTA to establish treatment priorities in these multiply injured patients. The mean age of the population was 35 years (43 men, 14 women). Hospital mortality was 24 percent; the most common cause of death was hemorrhage. Fully 95 percent of the patients had associated injuries requiring operative intervention. Abdominal injuries requiring laparotomy were present in 20 patients (35%): 14 splenic injuries, 8 liver injuries, 3 pancreatic injuries, and 3 mesenteric lacerations. Twenty-eight patients (49%) had orthopaedic injuries requiring operative fixation. Maxillofacial injuries requiring surgical repair occurred in 20 patients (35%). Fifteen patients (26%) sustained significant closed head injuries, but only 1 required craniotomy for hemorrhage. Nine hemodynamically unstable patients with intra-abdominal hemorrhage underwent immediate laparotomy for control of bleeding followed by aortography and aortic repair (2 deaths, 22%). Seven hemodynamically stable patients had aortography followed by laparotomy for control of intra-abdominal hemorrhage with subsequent thoracotomy (1 death, 14%). Thirty stable patients underwent aortography followed by immediate thoracotomy; 22 required no further procedures, while 8 required an additional operation (7 death, 23%).(ABSTRACT TRUNCATED AT 250 WORDS)