Examples of rotational thromboelastometric tracings. (A) Pre-treatment: traces obtained from a bleeding patient who incurred major trauma. Prolonged clotting time (CT) and late clot breakdown are notable on EXTEM. Fibrinogen level was on the borderline based on FIBTEM. Laboratory coagulation results were shown, but these results were not reported until the second ROTEM measurements were completed. Normal ranges for EXTEM and FIBTEM are as follows: EXTEM-CT 42–74 s, A10 43–65 mm, and MCF 49–71 mm; FIBTEM-A10 9–24 mm, MCF 9–25 mm. (B) On treatment: traces obtained after the initial treatment with 2 g of tranexamic acid and 4 g of fibrinogen along with ongoing 1:1 transfusion of RBCs and plasma. No improvement was seen in CT and MCF values of EXTEM. Fibrin polymerization was worsened on FIBTEM. (C) Normalized coagulation: traces obtained after the combined therapies using 1,200 IU of 4-factor PCC, 2 g of fibrinogen, and four units of platelets. Despite normal traces of EXTEM and FIBTEM, bleeding continued, and additional surgical hemostasis was established over the course of 8 h. The combination of allogeneic blood products and factor concentrates was crucial for managing massive volume depletion and ongoing bleeding. (D) Dosing of factor concentrates: the dose calculations for PCC and fibrinogen concentrate used in the protocol. BW = body weight. Adapted from the reference  with permission. MTP = massive transfusion protocol.