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    Chief Complaint


    Organ System


    Patent Pending

    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.

    When to Use
    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.


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    Next Steps
    Creator Insights


    • 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.


    Addition of assigned points.

    Facts & Figures

    Score interpretation:

    Score Thyroid Storm
    <25 Unlikely to represent thyroid storm
    25-44 Suggestive of impending thyroid storm
    ≥45 Highly suggestive of thyroid storm


    Evidence Appraisal

    The BWPS is based on a retrospective analysis of patients diagnosed with thyroid storm and was validated retrospectively against their medical records. American Thyroid Association (ATA) guidelines (2011) include the BWPS as diagnostic criteria for thyroid storm.

    The Japanese Thyroid Association (Akamizu et al) published an alternative system derived from literature review of thyroid storm cases and Japanese patients with thyroid storm in 2012. The Japanese Thyroid Association (JTA) criteria categorize patients based on aggregate presence of certain clinical features (CNS, fever, tachycardia, congestive heart failure, GI). In the JTA guidelines, a “definite” diagnosis of thyroid storm requires:

    • At least 1 CNS symptom plus ≥ 1 other symptoms OR
    • ≥ 3 symptoms other than CNS manifestations

    Overall, comparison of JTA criteria to BWPS demonstrated that of the 406 patients diagnosed of thyroid storm or impending/possible thyroid storm, 354 were identified as such by both scoring systems. Although these 2 scoring systems are mostly concordant, 41 additional patients were found to qualify for treatment by the BWPS, suggesting that the application of BWPS may lead to more aggressive treatment approach.


    Dr. Henry Burch

    About the Creator

    Henry Burch, MD, is an endocrinologist at the National Naval Medical Center in Bethesda, Maryland. He is one of two doctors at National Naval Medical Center who specialize in Endocrinology, Diabetes & Metabolism. His research interests include diagnosis and treatment of thyroid disorders.

    To view Dr. Henry Burch's publications, visit PubMed

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