A statement nobody could disagree with
On Monday 9 November 2026 the American College of Surgeons Committee on Trauma and the Society of Interventional Radiology published a joint position statement, Rapid Endovascular Hemorrhage Control in Trauma, simultaneously in the Journal of the American College of Surgeons and the Journal of Vascular and Interventional Radiology [1,2]. Its argument is that interventional radiologists belong on the trauma team from the start, not at the end of a long telephone chain, and that every Level I and Level II centre must be able to begin an embolisation within 60 minutes when a bleeding patient needs one.
It is difficult to find anyone who objects to that. This should make us suspicious. A document that surgeons and radiologists can both sign has usually put the disagreement somewhere quiet, and this one has put it in the definition of when the 60 minutes begin. That definition matters to anyone preparing for the ATLS examination, because it presses on the oldest rule in the circulation chapter: the bleeding patient who is not responding goes to the operating theatre, not to the scanner and not to a fluoroscopy suite at the far end of the radiology corridor.
What the statement actually says
The statement is an interpretation of an existing rule. Standard 4.15 of the ACS verification programme already requires Level I and II trauma centres to have the staff and facilities to begin an endovascular or interventional radiology procedure for haemorrhage control within 60 minutes when the clinical condition demands rapid intervention [2]. Centres have argued for years about what that sentence obliges them to do. The new document tells them.
It makes six practical recommendations [2]. Involve interventional radiology early, so that the choice of haemorrhage-control method is a shared one. Give priority to the patients most likely to benefit from rapid embolisation, which the authors identify as those who are haemodynamically unstable or who have continuing resuscitation requirements. Write a standard activation pathway that says who starts the consultation, who is allowed to activate the team, and how the angiography suite, anaesthesia, transport, nursing and radiographers are mobilised. Agree in advance how surgery and embolisation will run in parallel when a patient needs both. Measure the time from decision to arterial puncture, along with other milestones that expose bottlenecks. And treat delay as a quality problem, with debriefs, process mapping and case review.
The sentence that matters most sits in the abstract. The performance interval that Standard 4.15 refers to is the time from a shared decision by trauma surgery and interventional radiology to proceed, to arterial puncture [1]. Rapid intervention is expected above all in the labile patient in whom imaging has already shown something to embolise.
A clock that is very hard to fail
The evidence that time matters in embolisation is almost entirely evidence about time from the door. Matsushima and colleagues, using American registry data on 181 patients with blunt pelvic fracture who were embolised within four hours of admission, found that each additional hour to embolisation was associated with odds of in-hospital death 1.79 times higher (95% CI 1.11 to 2.91) [3]. At a busy and well-resourced Level I centre in Baltimore, Tesoriero and colleagues reviewed 344 patients who underwent pelvic angiography and found a median time to angiography of 286 minutes; the median time to embolisation was more than five hours [4]. Schwartz and colleagues in Houston showed that patients with bleeding pelvic fractures who arrived at night or at the weekend waited significantly longer for embolisation than those who arrived in office hours, and asked in their title whether trauma centres were delivering two standards of care [5].
Now apply the new definition to an invented but unremarkable case. A motorcyclist arrives at 02:00 on a Sunday with a pelvic binder in place and a systolic pressure that rises with resuscitation and then drifts. CT at 02:35 shows an arterial blush in the pelvis. The report is verbal at 02:50. The trauma registrar telephones the trauma consultant, who telephones the on-call interventional radiologist at 03:20. They discuss whether the patient is stable enough, whether the pelvis should be packed first, and whether the blush is really arterial. They agree to proceed at 03:50. The team is assembled from home and the femoral artery is punctured at 04:45.
That centre has met the standard with five minutes to spare. The patient has waited two hours and forty-five minutes. Every delay that the literature has actually measured, including recognition, imaging, reporting, the telephone chain and the negotiation between specialties, lies upstream of the moment the clock starts. The interval also ends at puncture and not at haemostasis, so a difficult selective catheterisation adds nothing to the recorded time. A metric that begins when two consultants agree has an unfortunate property: the later they agree, the easier it is to pass.
The defence of the definition deserves to be put properly, because it is a good one. Door-to-puncture time is hopelessly confounded by case mix. It penalises the centre whose patient needed a laparotomy first, or whose bleeding only declared itself on a second scan, or who arrived as a transfer with two hours already lost. A verification standard has to measure something the service being verified can control, and decision-to-puncture is exactly the part that belongs to the radiology rota, the porters and the suite. Nor is it a trivial interval. In a Japanese series of 158 patients embolised for pelvic fracture, the median time from decision to embolisation was 59.5 minutes, and a longer interval was associated with a higher risk of death on multivariable analysis [6]. And the statement does ask centres to record other milestones.
All of that is true. The difficulty is the difference between what is mandated and what is suggested. Verification visits audit the number in the standard. Hospitals improve the number that is audited. The upstream intervals, which is where the Baltimore patients lost their five hours, are left to local enthusiasm.
The doctrine it collides with
ATLS teaches a simple and durable sequence for the bleeding patient: find the source, stop the bleeding, and do not let investigation delay either. The patient who fails to respond to initial resuscitation and has an identified source in the abdomen goes to theatre. CT is for the patient stable enough to survive it. Within that scheme embolisation has traditionally been an adjunct for the patient who has earned it by remaining stable: the transient or partial responder with a pelvic fracture, or the solid-organ injury with a contrast blush that is being managed without an operation.
The joint statement does not say that the unstable patient should bypass theatre. But it gives priority for rapid embolisation to precisely the haemodynamically unstable group, and that is a change of emphasis with physical consequences. In most hospitals the angiography suite is further from the resuscitation room than theatre is, is not equipped for a laparotomy, has no scrub team, and is staffed out of hours by people who have driven in from home. Sending the sickest patients there is defensible only if the system around the suite has been rebuilt, which is of course the point the authors are making.
British readers will recognise the position, because NICE reached it a decade ago. The major trauma guideline NG39 recommends interventional radiology for active arterial pelvic haemorrhage unless immediate open surgery is needed to control bleeding from other injuries, and suggests it be considered for arterial bleeding from the spleen, liver or kidney [7]. The companion guideline on complex fractures, NG37, makes pelvic packing the first invasive step when the patient needs a laparotomy anyway [8]. A UK candidate therefore works in a system whose national guidance gives the catheter a larger role than the course traditionally has. The examination tests the course.
Why the surgeons are right to be wary
The sceptical case is stronger than a reflex defence of the scalpel. It has three parts.
The first is that there is a surgical alternative for the pelvis which does not depend on a second team. The Denver group led by Burlew reported preperitoneal pelvic packing in patients with life-threatening haemorrhage from unstable pelvic fractures, with a mortality of 21% in a very high-risk cohort; only about one in eight went on to need embolisation for a persisting arterial blush. They argued that embolisation takes three to five hours to deliver even in advanced centres, particularly at night and at weekends [9]. Two subsequent meta-analyses comparing packing with embolisation as the first intervention in unstable pelvic fracture found no difference in in-hospital mortality [10,11], and one found that embolisation started on average about 45 minutes later [10]. What the comparative evidence shows, in other words, is not that embolisation first is better. It shows that it is slower and no worse, in observational data of low quality.
The second is that trauma has recently been wrong about an endovascular intervention. The UK-REBOA trial randomised 90 patients with exsanguinating haemorrhage at 16 major trauma centres to aortic balloon occlusion plus standard care or standard care alone. It was stopped early. Mortality at 90 days was 54% with the balloon and 42% without, with an 86.9% posterior probability that the intervention increased the odds of death, and time to definitive haemorrhage control was longer in the balloon group [12]. The lesson is not that catheters are dangerous. It is that an endovascular step which postpones definitive control can kill, and that a decade of confident registry data did not reveal this.
The third is that every study linking faster embolisation to survival is retrospective. Confounding by indication runs in both directions: the sickest patients are hurried, and the very sickest die before they reach the suite and vanish from the denominator. Tesoriero and colleagues, whose five-hour figure is quoted in support of urgency, reported that time to angiography was not an independent predictor of death once injury severity was accounted for [4]. A 60-minute standard has been written on top of an association.
There is a reply to all three, and it comes from Japan. Since 2011 several Japanese centres have built hybrid emergency rooms in which CT, operative surgery and embolisation take place on the same table without moving the patient. Kinoshita and colleagues, comparing outcomes before and after installation in a retrospective historical-control study, reported improved survival in severe trauma [13]. On this view the argument between theatre and angiography suite is an artefact of architecture. The patient is unstable for transfer, not unstable for embolisation. The statement gestures at this with its call for parallel workflows, but a workflow is a much cheaper thing to recommend than a room.
The British problem: a clock with nobody to start it
It is tempting to read all this as an American accreditation dispute. It is not. The United Kingdom has had a timed standard for longer, and a stricter one. The Royal College of Radiologists said in 2011 that interventional radiology trauma teams should be in place within 60 minutes of the patient’s admission or within 30 minutes of referral [14]. NHS England guidance on seven-day services for major trauma centres specifies interventional radiology within 60 minutes of referral [15]. Both clocks start earlier than the new American one, and neither waits for consensus.
The difficulty is supply. The College’s 2022 workforce census found that only 48% of trusts and health boards could provide adequate round-the-clock interventional radiology [16]. Its 2025 census reported that 56% of clinical directors did not have enough interventional radiologists to deliver safe and effective care [17]. The College’s own view is that a sustainable on-call rota needs at least six. A trauma unit outside a major centre may have none available at 02:00, and the embolisation the guideline recommends then depends on a transfer. Schwartz’s two standards of care [5] are, in Britain, sometimes one standard and an ambulance.
This is where the joint statement, for all the softness of its clock, is right about the thing that matters. The delay in embolisation is rarely a slow radiologist. It is a system that treats the radiologist as a referral destination, to be persuaded, and not as a member of the team, to be activated. NICE’s service delivery guideline already lists interventional radiology among the departments a tiered trauma team response should mobilise for major haemorrhage [18]. A trauma team leader who can summon theatre with one call but must negotiate for the angiography suite with three is working with two different models of urgency.
What an honest standard would measure
If the profession believes the evidence it cites, the measurement should match it. Three intervals, not one: arrival (or CT) to decision; decision to puncture; puncture to haemostasis. The first belongs to the trauma team, the second to the radiology service, the third to the operator and the anatomy. Each has a different owner and a different remedy, and reporting only the middle one protects the two specialties from each other at the expense of the patient. Activation should sit with the trauma team leader on predefined criteria, with the discussion happening while people travel and not before they are called. And the centres that cannot staff a rota should say so in their network agreements, so that the decision to pack, or to transfer, is made at minute ten and not at minute ninety.
None of this needs a hybrid suite. It needs the same thing the statement asks for, taken one step further than its authors were able to agree.
What this means for your ATLS exam
The position statement changes how good centres should organise themselves. It does not change the answers on the paper. Hold on to the following.
- The non-responder goes to theatre. A patient who remains haemodynamically abnormal despite resuscitation, with a positive FAST or another clear abdominal source, needs a laparotomy. An option that sends this patient to CT, CT angiography or the angiography suite is the distractor.
- Know where embolisation sits. It is a haemorrhage-control option for arterial pelvic bleeding and for selected solid-organ injuries, classically in the patient who has responded at least transiently. Expect it as the correct answer when the abdomen has been excluded as the source and the patient is stable enough to get there.
- For the pelvis, think in sequence. Suspect the injury from mechanism, apply a binder early at the level of the greater trochanters, look for a second source in the abdomen and chest, then choose between embolisation, preperitoneal packing and external fixation according to the patient’s physiology and what the hospital can deliver.
- Resources decide. If the capability for definitive haemorrhage control is not available, the answer is early transfer, and transfer is not delayed for imaging that will not change the decision to go.
- Definitive care is not always an operation. Questions on team preparation and communication increasingly reward the candidate who mobilises help before it is needed. Calling interventional radiology at pre-alert for a high-energy pelvic injury is the behaviour the eleventh edition’s emphasis on teamwork is asking for.
- Watch the stem for the response to resuscitation. Rapid responder, transient responder and non-responder are the three words that determine whether the next step is observation, imaging and embolisation, or the knife.
The rule that the unstable patient goes to theatre was written for hospitals in which theatre was the only place bleeding could be stopped. That is no longer true everywhere. It is still true in the examination hall, and in most British hospitals at two in the morning.
References
1. Wilkins LR, et al. Rapid endovascular hemorrhage control in trauma: joint position statement from the American College of Surgeons Committee on Trauma and the Society of Interventional Radiology. J Am Coll Surg. Published ahead of print 9 November 2026. doi:10.1097/XCS.0000000000002254. Co-published in J Vasc Interv Radiol. doi:10.1016/j.jvir.2026.108978.
2. American College of Surgeons. ACS and SIR call for rapid, team-based endovascular hemorrhage control in trauma care [press release]. 9 November 2026. https://www.facs.org/media-center/press-releases/2026/acs-and-sir-call-for-rapid-team-based-endovascular-hemorrhage-control-in-trauma-care/
3. Matsushima K, Piccinini A, Schellenberg M, et al. Effect of door-to-angioembolization time on mortality in pelvic fracture: every hour of delay counts. J Trauma Acute Care Surg. 2018;84(5):685-692. doi:10.1097/TA.0000000000001803.
4. Tesoriero RB, Bruns BR, Narayan M, et al. Angiographic embolization for hemorrhage following pelvic fracture: is it “time” for a paradigm shift? J Trauma Acute Care Surg. 2017;82(1):18-26. doi:10.1097/TA.0000000000001259.
5. Schwartz DA, Medina M, Cotton BA, et al. Are we delivering two standards of care for pelvic trauma? Availability of angioembolization after hours and on weekends increases time to therapeutic intervention. J Trauma Acute Care Surg. 2014;76(1):134-139. https://researchexperts.utmb.edu/en/publications/are-we-delivering-two-standards-of-care-for-pelvic-trauma-availab/
6. Mizuno Y, Miyake T, Okada H, et al. A short decision time for transcatheter embolization can better associate mortality in patients with pelvic fracture: a retrospective study. Front Med. 2024;10:1329167. doi:10.3389/fmed.2023.1329167.
7. National Institute for Health and Care Excellence. Major trauma: assessment and initial management. NICE guideline NG39. 2016. https://www.nice.org.uk/guidance/ng39/chapter/recommendations
8. National Institute for Health and Care Excellence. Fractures (complex): assessment and management. NICE guideline NG37. 2016, updated 2022. https://www.nice.org.uk/guidance/ng37/chapter/recommendations
9. Burlew CC, Moore EE, Stahel PF, et al. Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. J Trauma Acute Care Surg. 2017;82(2):233-242. https://pmc.ncbi.nlm.nih.gov/articles/PMC5250563
10. Migliorini F, Cocconi F, Schipper I, et al. Arterial angioembolisation versus pre-peritoneal pelvic packing in haemodynamically unstable patients with complex pelvic fractures: a meta-analysis. Eur J Trauma Emerg Surg. 2024. doi:10.1007/s00068-023-02389-4.
11. Martinez B, Breeding T, Katz J, et al. Outcomes of preperitoneal packing and angioembolization for hemorrhage control in hemodynamically unstable pelvic fractures: a systematic review and meta-analysis. Am Surg. 2024. https://pubmed.ncbi.nlm.nih.gov/37970830/
12. Jansen JO, Hudson J, Cochran C, et al. Emergency department resuscitative endovascular balloon occlusion of the aorta in trauma patients with exsanguinating hemorrhage: the UK-REBOA randomized clinical trial. JAMA. 2023;330(19):1862-1871. doi:10.1001/jama.2023.20850.
13. Kinoshita T, Yamakawa K, Matsuda H, et al. The survival benefit of a novel trauma workflow that includes immediate whole-body computed tomography, surgery, and interventional radiology, all in one trauma resuscitation room: a retrospective historical control study. Ann Surg. 2019;269(2):370-376. doi:10.1097/SLA.0000000000002527.
14. Royal College of Radiologists. Standards of practice and guidance for trauma radiology in severely injured patients. London: RCR; 2011. https://www.bsir.org/media/resources/Trauma_standards_RCR_2011.pdf
15. NHS England. Seven day services clinical standards: guidance for major trauma. 2017. https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2017/02/guidance-major-7ds.pdf
16. Royal College of Radiologists. Clinical radiology workforce census 2022. London: RCR; 2023. https://www.rcr.ac.uk/media/qs0jnfmv/rcr-census_clinical-radiology-workforce-census_2022.pdf
17. Royal College of Radiologists. Clinical radiology workforce census 2025 (as reported 12 June 2025). https://www.lexology.com/library/detail.aspx?g=2e4644ab-a7d6-42dc-bb91-6a0051ae9420
18. National Institute for Health and Care Excellence. Major trauma: service delivery. NICE guideline NG40. 2016. https://www.nice.org.uk/guidance/ng40/chapter/recommendations