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    Burch-Wartofsky Point Scale (BWPS) for Thyrotoxicosis

    Predicts likelihood that biochemical thyrotoxicosis is thyroid storm.
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    INSTRUCTIONS

    Use in patients ≥18 years old with biochemical thyrotoxicosis.

    When to Use
    Pearls/Pitfalls
    Why Use

    Patients with thyrotoxicosis in the setting of systemic decompensation.

    • The Burch-Wartofsky Point Scale (BWPS) is a quantitative diagnostic tool based on 3 major observations in patients with thyroid storm:
      • Continuum of end organ dysfunction.
      • High variability of symptoms and signs between patients.
      • High mortality associated with missed diagnosis.
    • Assigns points for dysfunction of thermoregulatory, GI, cardiovascular, and central nervous systems.
    • Given the high mortality/morbidity associated with thyroid storm, the BWPS intentionally utilizes liberal criteria, which may also lead to false-positives.
    • Elderly patients may present with apathetic thyrotoxicosis with atypical symptoms (weakness, memory loss, obtundation, cardiac failure).
    • Serum levels of T4 and T3 do NOT correlate with severity of thyrotoxicosis.
    • Presence of jaundice suggests especially poor prognosis.
    • Ultimately, thyroid storm is a clinical diagnosis and requires prompt recognition and treatment.

    Can help distinguish uncomplicated thyrotoxicosis from “impending” storm or established thyroid storm.

    <99
    0
    99–99.9 (37.2-37.7)
    +5
    100–100.9 (37.8-38.2)
    +10
    101–101.9 (38.3-38.8)
    +15
    102–102.9 (38.9-39.2)
    +20
    103–103.9 (39.3-39.9)
    +25
    ≥104.0 (≥ 40.0)
    +30
    Absent
    0
    Mild (agitation)
    +10
    Moderate (seizures, coma)
    +20
    Severe (seizures, coma)
    +30
    Absent
    0
    Moderate (diarrhea, nausea/vomiting, abdominal pain)
    +10
    Severe (unexplained jaundice)
    +20
    <90
    0
    90-109
    +5
    110-119
    +10
    120-129
    +15
    130-139
    +20
    ≥140
    +25
    Absent
    0
    Mild (pedal edema)
    +5
    Moderate (bibasilar rales)
    +10
    Severe (pulmonary edema)
    +15
    No
    0
    Yes
    +10
    No
    0
    Yes
    +10

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    • BWPS ≥45 is highly suggestive of thyroid storm; consider rapid and aggressive multimodal management in ICU.
    • BWPS 25-44 suggests impending thyroid storm; consider thionamides, symptom management. Consider ICU monitoring.
    • BWPS <25 is unlikely to represent thyroid storm; investigate diagnosis of thyrotoxicosis (Graves disease, toxic adenoma, toxic multinodular goiter, subacute thyroiditis, exogenous levothyroxine, struma ovarii) and obtain additional imaging (thyroid ultrasound, radioactive iodine uptake and scan).

    Management

    Search for potential precipitant(s) of thyroid storm: infection, thyroidal/nonthyroidal surgery, medications (anesthetics, pseudoePHEDrine, amiodarone), iodinated contrast exposure, DKA, exogenous thyroid hormone, CVA, MI, PE.

    • Target treatment towards thyroid hormone formation, release, and adrenergic action:
      • Anti-thyroid drug therapy (propylthiouracil, methIMAzole)
      • Potassium iodine
      • Beta-blockade (propranolol, esmolol)
      • Corticosteroid (hydrocortisone)
      • Supportive care (fluids, acetaminophen)
      • ICU level care

    Critical Actions

    • Iodine therapy should be administered at least 1 hour AFTER thionamides to prevent stimulation of new thyroid hormone synthesis
    • Avoid aspirin because it displaces T4 from thyroid binding globulin, resulting in increase of free T4.
    • TItrate beta blockers carefully as excessive doses in thyrotoxic patients can cause cardiovascular collapse.
    • Besides reducing T4 to T3 conversion, steroids provide adrenal support, which can be impaired in thyroid storm.
    Content Contributors
    • Anika Anam, MD
    About the Creator
    Dr. Henry Burch
    Are you Dr. Henry Burch?
    Content Contributors
    • Anika Anam, MD