This document provides an overview of ROTEM testing, which can measure whole blood clotting over time. It summarizes the four main ROTEM tests: EXTEM, FIBTEM, INTEM, and HEPTEM, which measure clotting via different pathways. The document then outlines a 4 step approach to interpret ROTEM results and guide treatment decisions for fibrinogen, platelets, clotting factors, and hyperfibrinolysis based on the A5 and CT values from EXTEM and FIBTEM tests. It emphasizes that ROTEM can provide answers in 10 minutes, unlike standard coagulation tests that take hours, and can help guide transfusion of blood products like platelets,

1. ROTEM
A Cook’s Tour /
Idiots Guide

4. ROTEM
• Physical properties of whole blood
• clot formation time
• clot stength / size / thickness
• clot lysis time
• TEG vs ROTEM
• ROTEM Vs Massive Transfusion Protocols Vs SLTs
• Gets answers in 10 minutes vs hours

10. • EXTEM - measures clot formation via Extrinsic pathway
• FIBTEM - same as EXTEM but platelets inhibited
• INTEM - measures clot formation via Intrinsic pathway
• HEPTEM - same as INTEM but heparin inhibited

11. EXTEM
Extrinsic pathway activation
Tissue Factor pathway
FIBTEM
Action of platelets
removed -
removes their role
=

12. INTEM
Intrinsic coag pathway
aka contact activation
=
HEPTEM
action of heparin
removed with
heparinase

17. STEP 1 - Do they need Fibrinogen
• Look at FIBTEM
• A5 is very low = A5 < 10mm = very poor quality clot is forming
• = NEEDS FIBRINOGEN (cryoprecipitate)

18. STEP 2 - Do they need Platelets
• Look At EXTEM
• A5 is low (< 35mm)
• Look at FIBTEM
• A5 is not too bad (A5 > 10mm)
• EXTEM is worse than FIBTEM = NEEDS PLATELETS

19. Step 3 - Do they need Factors
(FFP)
• Look at EXTEM
• Is CT very long (>80 sec)
• Look at FIBTEM
• A5 not too bad (>10 mm)
• = NEEDS FFP

20. Step 4 - Is there Hyperfibrinolysis
• Forget about this for now…..
• CRASH 2 Trial
• Transexamic acid in trauma (1g over 10 mins followed by 1g over 8 hours = improved outcomes if
given within 3 hours
• The WOMEN Trial: Early TXA in post partum haemorrhage
• Similar results —> mortaility benefit (bleeding) if given early

22. Step 1

24. Step 2

26. Step 3

28. In summary…
• If triggering massive transfusion protocol send for blood for ROTEM
• Treat as currently do 2 PRBC :1 FFP +/- 1 Platelets, 1g TXA, 10U cryoprecipitate
• Monitor ROTEM on computer at the end
• Look at :
• EXTEM and FIBTEM
• CT and A5
• fat is good, thin is bad
• After any intervention, re-send and monitor