Background Rotational thromboelastometry (ROTEM) allows targeted and individualised blood product replacement. Objectives The study aimed to determine the impact of ROTEM-guided transfusion on the clinical course of patients with acute massive haemorrhage in a regional Australian hospital. Methods/Materials A retrospective review of all patients with acute massive haemorrhage that compared the characteristics, blood product use, and clinical outcomes of patients with massive haemorrhage before and after the introduction of ROTEM-guided transfusion. Results In per-protocol analysis, the 31/97 (32%) with ROTEM-guided transfusion used less packed red blood cells (median [interquartile range]: 6 [6–8] vs. 8 [6–12] units, p = 0.03) than patients whose transfusion was not ROTEM-guided. They were also less likely to receive fresh frozen plasma (2/31 [6%] vs. 45/66 [68%], p < 0.0001) or platelets (2/31 [6%] vs. 31/66 [47%], p < 0.0001); they were, however, more likely to receive fibrinogen products (26/31 [84%] vs. 38/66 [58%], p = 0.01). Patients receiving ROTEM-guided transfusion had lower in-hospital mortality (6/31 [19%] vs. 20/66 [30%], odds ratio 0.55 [95% confidence interval]: 0.20–1.55, p = 0.26) although this did not achieve statistical significance in this small cohort. Conclusion ROTEM-guided massive transfusion of patients with acute haemorrhage in this regional Australian hospital led to a reduction in packed red blood cell, fresh frozen plasma, and platelet utilisation and may also have reduced mortality.