A systematic review of the published literature clearly demonstrates the usefulness of thromboelastometry (ROTEM®) in detecting coagulation disorders in severe trauma, cardiac and aortic surgery, liver transplantation, and postpartum haemorrhage reliably and within a clinically acceptable turn-around time. In all of the above-mentioned scenarios, the transfusion of any allogeneic blood products could be reduced significantly using ROTEM®-guided bleeding management, thereby minimising or avoiding transfusion-related side effects. Based on the current body of evidence as assessed by the GRADE system, the use of ROTEM® may be recommended in particular for management of severe bleeding after trauma and during cardiac and aortic surgery. However, as laboratory testing contributes only one part of severe bleeding management, the implementation of safe and effective treatment algorithms must be ensured at the same time.