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Age (years)
Select ASA
1 (No systemic disease)
2 (Mild systemic disease)
3 (Severe systemic disease)
4 (Life-threatening systemic disease)
5 (Moribund patient)
ASA grade
GCS
Heart rate (BPM)
Systolic blood pressure (mmHg)
White Cell Count (×10
9
/L)
Sodium (mmol/L)
Potassium (mmol/L)
Urea (mmol/L)
Creatinine (mmol/L)
Lactate and Albumin can be left blank
Lactate (mmol/L)
Albumin (g/L)
Cardiac arrhythmia?
No
Yes
Excludes sinus tachycardia. Includes rate-controlled AF.
CT abdo/pelvis performed?
No
Yes
Select indication
Small bowel obstruction
Large bowel obstruction
Perforation
Peritonitis
Ischaemia
Haemorrhage
Colitis
Abdominal abscess
Anastomotic leak
Incarcerated hernia
Volvulus
Other
Indication for surgery
Select cardiac status
None
Diuretic, digoxin, Rx for angina or hypertension
Peripheral oedema, warfarin, borderline cardiomegaly
Raised JVP, cardiomegaly
Cardiac status
Select respiratory status
None
Dyspnoea on exertion, mild COAD
Limiting dyspnoea, moderate COAD
Dyspnoea at rest, pulmonary fibrosis/consolidation
Respiratory status
Select malignancy
None
Primary only
Nodal metastasis
Distant metastasis
Malignancy
Select peritoneal soiling
None
Serous fluid
Local pus
Free bowel content, pus or blood
Peritoneal soiling
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