Recombinant activated factor VII (rFVIIa) has recently gained wide attention as a potent prohaemostatic agent for patients with excessive or life-threatening blood loss. Originally licensed for the treatment of patients with bleeding haemophilia with antibodies to factor VIII or IX, rFVIIa is now being used on an off-label basis to thwart blood loss in a variety of other clinical situations. Despite concerns over the drug's cost, risk profile and the lack of large-scale clinical trials validating its use, more and more patients are being treated with rFVIIa in the emergency department. With few clinical trials available to guide its administration, emergency physicians must weigh the existing evidence when considering whether to use rFVIIa for their patients with bleeding. This paper reviews the current literature regarding rFVIIa as it pertains to the practice of emergency medicine.