Purpose Ruptured abdominal aortic aneurysm (rAAA) is a time-critical surgical emergency with mortality up to 85%. Survival is contingent on rapid progression from emergency presentation to operative intervention. We describe the development of an endovascular-first protocol targeting reduction in door-to-knife time and contextualise it against a 10-year operative experience at Austin Health. Methodology The protocol was developed through systematic review of established rAAA management algorithms, with reduction in door-to-knife time as its central design principle. Institutional context was derived from a retrospective cohort study of all rAAA presentations at the centre between January 2016 and December 2025. Case identification employed a multi-source strategy incorporating emergency department records, AVA database, ICU admission data, and mortality and morbidity meeting records. Door-to-knife time was sub-divided into four discrete intervals and the VSGNE rAAA risk score was applied retrospectively to all operative cases. Results Thirty-three operative rAAA cases were identified: 12 EVAR (36%) and 21 open surgical repair (OSR) (64%). Preliminary data demonstrate a median door-to-knife time of 74 minutes for EVAR versus 264 minutes for OSR, reflecting theatre mobilisation delays the protocol is designed to eliminate. Median length of stay was 10 days for EVAR versus 16 days for OSR, with in-hospital mortality of 17% and 33% respectively. A suprarenal clamp was required in 62% of OSR cases highlighting anatomical complexity. Conclusion Door-to-knife time is a critical and modifiable determinant of survival in rAAA and varies substantially by operative approach. The proposed endovascular-first protocol provides a structured framework to standardise care and reduce time-to-intervention therefore improving patient outcomes.