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Burch-Wartofsky Point Scale (BWPS) for Thyrotoxicosis

Determines likelihood of thyrotoxicosis independent of thyroid hormone levels.

Use in patients ≥18 years old with biochemical thyrotoxicosis.

About the Creator
Dr. Henry Burch
Content Contributors
  • Anika Anam, MD


  • 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).


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