The emergency general surgery (EGS) patient population is growing and may present with a wide range of acute diseases. In particular for those patients requiring emergency laparotomy for severe abdominal sepsis, expeditious and systematic initial assessment and resuscitation is critical and has a direct impact on different outcome levels. The history and careful physical examination are the cornerstones of the initial assessment, as these clinical findings are major determinants of surgical decision-making. In contrast to elective surgery, emergency cases limit the time for resuscitation and prehabilitation. This is even more important in the fastest growing group of frail EGS patients, the elderly and multimorbid, with limited physiological reserves. Especially in times of reduced resources, efficient treatment pathways and careful risk stratification of this vulnerable patient population are needed, however, without reducing the quality of patients care.