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Hematology · Interpreter

TEG / ROTEM: what to give

Tick what your TEG or ROTEM report flags as abnormal. For each finding: what it means and, if the patient is bleeding, which product addresses it, in what order, with the guideline behind it. No analyzer settings, no numbers to type.

Tick the flagged findingsDirections only when bleedingTrauma · cardiac · liver · obstetricReviewed Oct 2026

1What the report flags

Tick every abnormal finding your lab's report flags. Cut-offs vary by analyzer and cartridge, so use the report's own flags.

2Patient

Directions are given only for a bleeding patient. Not bleeding: interpretation only.

How it works

Using your report

Your lab's report flags what's abnormal; cut-offs vary by analyzer and cartridge. The tool works from those flags, not from numbers. It gives a direction for each flagged finding in a bleeding patient and only an interpretation when the patient is not bleeding. Repeat the test after treatment: the European guideline recommends early and repeated monitoring of hemostasis (R11) and continuing resuscitation goal-directed by laboratory values and/or VET (R26).

FindingMeaningDirection when bleeding
R / CT prolongedSlow clot initiation: low coagulation factors, heparin or another anticoagulantHeparin reversal is always the first step. Heparinase or HEPTEM corrects it into range: reverse heparin, no plasma. Partial correction: reverse heparin, recheck, then treat initiation. No comparison run: check for heparin before plasma (after bypass always; elsewhere if the patient may have had heparin). Otherwise plasma (R27) or, with normal fibrinogen, PCC (R28); fibrinogen first when it is low.
K / α-angle, CFTSlow clot build. Gonzalez 2016 links angle with fibrinogen; TQIP lists plasma and/or cryoprecipitate for it, so it is not specificFibrinogen only when FF / FIBTEM or Clauss fibrinogen is low (R29)
MA / MCF lowWeak clot: platelets, fibrinogen or both; the functional fibrinogen assay (FF, CFF, FIBTEM) blocks platelets and separates themFibrinogen low: fibrinogen first. Normal: platelets (R30). Not done: check FF / FIBTEM or Clauss.
LY30 / ML highHyperfibrinolysisTrauma within 3 h: TXA (R23; TQIP). After 3 h: starting TXA is unsupported. Obstetric: TXA by time from birth.
R / CT short, MA / MCF highHypercoagulable featuresNo product is given for these findings
LY30 very low after injuryFibrinolysis shutdown (Moore 2014: LY30 0–0.8%)Named only; never treated

Contradictory ticks stop the page: LY30 both high and very low, or "Nothing flagged" with a finding. R/CT both prolonged and short, or MA/MCF both low and high, can happen across different assays or channels (for example INTEM CT prolonged with EXTEM CT short), so those show a warning to check the report instead of stopping.

The product doses come from the European trauma guideline (2023). Outside trauma they are given as a general direction; your setting's protocol takes precedence. No plasma dose is shown because the guideline gives none.

Evidence: in the ITACTIC trial (396 trauma patients), adding VET to a major hemorrhage protocol did not improve the share alive and free of massive transfusion at 24 h compared with conventional tests (67% vs 64%). Liver transplantation is outside the scope of this tool.

Example published trauma cut-offs (not used by this tool)

Examples only, to show how published algorithms define "abnormal". The tool does not apply them; each depends on its analyzer and assay.

SourceExample cut-offs
Gonzalez 2016 RCT (RapidTEG, TEG 5000)ACT over 110 s: 2 units plasma · angle under 63°: 10-pack cryoprecipitate · MA under 55 mm: 1 apheresis platelet unit · LY30 7.5% or more (lowered to 3% or more after 31 August 2012): TXA 1 g, within 3 h of injury
ITACTIC (Trials 2017, Fig. 3; ROTEM and rapid TEG)FIBTEM A5 under 10 mm or FF MA under 20 mm: 4 g fibrinogen equivalent · EXTEM A5 minus FIBTEM A5 under 30 mm, or rapid TEG MA minus FF MA under 45 mm: 1 pool of platelets · EXTEM A5 40 mm or more with EXTEM CT over 80 s, or rapid TEG MA 65 mm or more with ACT over 120 s: 4 units of plasma · EXTEM LI30 under 85% or LY30 over 10%: an additional 1 g TXA
ACS TQIP 2014 (standard TEG, rapid TEG, ROTEM)Listed under "Endpoints of Transfusion": goal-directed transfusion once surgical bleeding is controlled; ratio-based massive transfusion before that. Standard TEG: R over 9 min plasma; K over 4 min plasma and/or cryo; angle under 60° cryo and/or plasma; MA under 55 mm platelets; LY30 over 7.5% antifibrinolytic. Rapid TEG: ACT over 128 s; K over 2.5 min; angle under 60°; MA under 55 mm; LY30 over 3%. ROTEM: EXTEM CT over 100 s and/or INTEM CT over 230 s plasma; FIBTEM MCF under 8 mm cryo and/or plasma; EXTEM MCF under 45 mm with FIBTEM MCF over 10 mm platelets; EXTEM ML over 15% antifibrinolytic.
FDA reference ranges (reference only)

From the FDA 510(k) decision summaries; each advises labs to establish their own ranges. Your report's flags take precedence.

  • TEG 6s, CK / CKH / CRT / CFF (K150041; CK LY30 K183160): CK R 4.6–9.1 min · K 0.8–2.1 min · angle 63.1–77.6° · MA 51.6–68.7 mm · LY30 0–2.6% · CKH R 4.3–8.3 min · CRT MA 52.4–69.7 mm · CFF MA 15.2–31.9 mm.
  • TEG 6s, K / KH / RTH / FFH (K232018): CK R 4.6–9.1 min · CK MA 52–69 mm · CKH R 4.3–8.3 min · CKH LY30 0–3.2% · CRTH MA 53–69 mm · CFFH MA 15–34 mm.
  • ROTEM delta (K101533, K083842): EXTEM CT 43–82 s · CFT 48–127 s · MCF 52–70 mm · FIBTEM MCF 7–24 mm · INTEM/HEPTEM CT 122–208 s.
  • ROTEM sigma complete + hep (K201440): EXTEM CT 51–73 s · A5 33–52 · A10 45–62 · MCF 57–72 mm · ML 0–6% (INTEM 0–7%), calculated at 60 min after CT · FIBTEM A5 5–16 · A10 6–17 · MCF 6–19 mm · INTEM CT 139–205 s · HEPTEM CT 141–215 s.
  • No IFU or FDA range could be retrieved for TEG 5000 assays.
Setting notes

Trauma: TQIP 2014 gives plasma:RBC 1:1 to 1:2 and one platelet dose per 6 RBC units until laboratory data are available, then goal-directed transfusion once surgical bleeding is controlled; laboratory and POC tests at least hourly in the ICU. R25 (European): FFP:pRBC at least 1:2 with a high platelet:pRBC ratio, or fibrinogen concentrate or cryoprecipitate with pRBC. R12: avoid routine POC platelet-function devices in trauma patients on antiplatelet therapy or with suspected platelet dysfunction.

Cardiac surgery: STS 2021 recommends goal-directed transfusion algorithms that use point-of-care testing such as VET (Class I, B-R); the 2024 EACTS/EACTAIC guideline (European) recommends perioperative treatment algorithms based on viscoelastic POC testing for the bleeding patient (Class I, A) and recommends against routine viscoelastic or platelet-function testing to predict bleeding (Class III, C). STS: prophylactic plasma without coagulopathy, Class III harm; synthetic antifibrinolytics are indicated for blood conservation (Class I, A).

Liver disease: AASLD 2020: VET systematically underestimates coagulation capacity in cirrhosis and is not sensitive to moderate or mild hyperfibrinolysis; prophylactic EACA or TXA to prevent procedural bleeding cannot be recommended. AGA 2021 makes no recommendation on pre-procedure VET and suggests against routine FFP or platelets before common procedures in stable cirrhosis. EASL 2022 does not generally indicate traditional or viscoelastic tests to predict procedural bleeding. Variceal bleeding: AASLD 2024 advises against FFP or platelets to INR or count targets. Liver transplantation is out of scope.

Obstetric: WOMAN: TXA 1 g IV, second 1 g if bleeding continued after 30 min or restarted within 24 h; it cut death from bleeding, most when given within 3 h of birth. WHO 2017 recommends TXA as early as possible and within 3 h of birth, and recommends against starting it more than 3 h after birth. OBS2: fibrinogen concentrate triggered by FIBTEM A5 ≤15 mm did not improve outcomes; prespecified subgroup analyses suggest replacement is not required if FIBTEM A5 is above 12 mm or Clauss fibrinogen above 2 g/L, and the raised fibrinogen at term appears to be a physiological buffer.

Sources

  1. Rossaint R, Afshari A, Bouillon B, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023;27:80. doi:10.1186/s13054-023-04327-7 (PMC9977110; recommendations 11, 12, 18, 23, 25–36 and rationales).
  2. CRASH-2 collaborators. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet 2011;377:1096–101. doi:10.1016/S0140-6736(11)60278-X
  3. American College of Surgeons Trauma Quality Improvement Program. ACS TQIP Massive Transfusion in Trauma Guidelines. Released October 2014 (current on facs.org, checked 2026-10-19): ratios, TXA, PCC licensing, repeat testing, Endpoints of Transfusion; laboratory triggers (shown as examples only).
  4. Bouzat P, Charbit J, Abback PS, et al. Efficacy and safety of early administration of 4-factor prothrombin complex concentrate in patients with trauma at risk of massive transfusion: the PROCOAG randomized clinical trial. JAMA 2023;329(16):1367–75. doi:10.1001/jama.2023.4080
  5. Gonzalez E, Moore EE, Moore HB, et al. Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial. Ann Surg 2016;263(6):1051–9. doi:10.1097/SLA.0000000000001608 (example cut-offs only).
  6. Baksaas-Aasen K, Gall L, Eaglestone S, et al. iTACTIC study protocol. Trials 2017;18:486. doi:10.1186/s13063-017-2224-9 (Fig. 3; example cut-offs only). Trial: Baksaas-Aasen K, Gall LS, Stensballe J, et al. Intensive Care Med 2021;47(1):49–59. doi:10.1007/s00134-020-06266-1
  7. Moore HB, Moore EE, Gonzalez E, et al. Hyperfibrinolysis, physiologic fibrinolysis, and fibrinolysis shutdown. J Trauma Acute Care Surg 2014;77(6):811–7. doi:10.1097/TA.0000000000000341
  8. Ostrowski SR, Johansson PI. Endothelial glycocalyx degradation induces endogenous heparinization in patients with severe injury and early traumatic coagulopathy. J Trauma Acute Care Surg 2012;73(1):60–6. doi:10.1097/TA.0b013e31825b5c10
  9. Tibi P, McClure RS, Huang J, et al. STS/SCA/AmSECT/SABM update to the clinical practice guidelines on patient blood management. Ann Thorac Surg 2021;112(3):981–1004. doi:10.1016/j.athoracsur.2021.03.033
  10. Casselman FPA, Lance MD, Ahmed A, et al. 2024 EACTS/EACTAIC guidelines on patient blood management in adult cardiac surgery in collaboration with EBCP. Eur J Cardiothorac Surg 2025;67(5):ezae352. doi:10.1093/ejcts/ezae352 (PMC12257489; Recommendation Tables 1, 8, 10 and 11; sections 5.1.2–5.1.4).
  11. Protamine Sulfate Injection, USP. US prescribing information, Fresenius Kabi (DailyMed setid c76876da-b9a8-45d0-9278-7df3288d3a06). Boxed warning; Warnings; Precautions; Overdosage; Dosage and Administration.
  12. Northup PG, Garcia-Pagan JC, Garcia-Tsao G, et al. Vascular liver disorders, portal vein thrombosis, and procedural bleeding in patients with liver disease: 2020 practice guidance by the AASLD. Hepatology 2021;73(1):366–413. doi:10.1002/hep.31646
  13. O'Shea RS, Davitkov P, Ko CW, et al. AGA clinical practice guideline on the management of coagulation disorders in patients with cirrhosis. Gastroenterology 2021;161(5):1615–27. doi:10.1053/j.gastro.2021.08.015
  14. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol 2022;76(5):1151–84. doi:10.1016/j.jhep.2021.09.003
  15. Kaplan DE, Ripoll C, Thiele M, et al. AASLD practice guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024;79(5):1180–211. doi:10.1097/HEP.0000000000000647 (statement 29).
  16. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN). Lancet 2017;389:2105–16. doi:10.1016/S0140-6736(17)30638-4
  17. World Health Organization. WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhage. Geneva: WHO; 2017. ISBN 978-92-4-155015-4 (wording taken from the WHO TXA key-messages brief, https://www.mcsprogram.org/wp-content/uploads/2017/11/WHO-TXA-Briefer-A4.pdf, and its summary on rhsupplies.org; the WHO guideline PDF itself could not be opened). Summary: Vogel JP, et al. Lancet Glob Health 2018;6(1):e18–9. doi:10.1016/S2214-109X(17)30428-X
  18. American College of Obstetricians and Gynecologists. Practice Bulletin No. 183: Postpartum hemorrhage. Obstet Gynecol 2017;130(4):e168–86. Not opened; TXA statement as summarized by the UIC Drug Information Group (March 2022).
  19. Collins PW, Cannings-John R, Bruynseels D, et al. Viscoelastometric-guided early fibrinogen concentrate replacement during postpartum haemorrhage (OBS2). Br J Anaesth 2017;119(3):411–21. doi:10.1093/bja/aex181
  20. US Food and Drug Administration. Update on the safety of Andexxa (andexanet alfa). FDA safety communication, content current as of 18 Dec 2025: FDA considers the risks to outweigh the benefits (ANNEXA-I thrombosis 14.6% vs 6.9%); US commercial sales ended by 22 Dec 2025. fda.gov/vaccines-blood-biologics/safety-availability-biologics/update-safety-andexxa
  21. TCTMD. Andexanet alfa pulled from US market. 22 Dec 2025. https://www.tctmd.com/news/andexanet-alfa-pulled-us-market
  22. US FDA 510(k) decision summaries K150041, K183160, K232018 (TEG 6s), K083842, K101533 (ROTEM delta), K201440 (ROTEM sigma): reference ranges, heparinase and HEPTEM function, measurement temperature, interference testing. accessdata.fda.gov, accessed 2026-10-19.

Educational reference only — not a substitute for clinical judgment, institutional protocols, or specialist advice. Calculations run in your browser; nothing you enter is sent or stored.