Burch-Wartofsky Score
What It Is
The Burch-Wartofsky Point Scale (BWPS) is a clinical scoring system that uses specific criteria to diagnose thyroid storm, with scores ≥45 points highly suggestive of thyroid storm and scores ≥25 points suggesting impending storm. 1, 2
The scoring system evaluates multiple clinical parameters to distinguish thyroid storm from uncomplicated thyrotoxicosis, though it has limitations in specificity, particularly during concurrent infections. 1
Clinical Application
When to Use the Score
Apply the BWPS in any patient with known or suspected hyperthyroidism presenting with fever, tachycardia disproportionate to fever, altered mental status, gastrointestinal symptoms, or cardiac arrhythmias. 3
Do not delay treatment while awaiting laboratory confirmation or calculating the exact score if clinical suspicion is high, as mortality rises significantly with treatment delays. 3
Score Interpretation
Scores ≥45 points are highly suggestive of thyroid storm and mandate immediate aggressive treatment. 2
Scores of 25-44 points suggest impending thyroid storm requiring close monitoring and early intervention. 4
The BWPS has been helpful in establishing diagnosis and deciding when to initiate advanced therapies like therapeutic plasma exchange. 4
Critical Limitations
The BWPS has relatively low specificity, especially in patients with viral or bacterial infections (including COVID-19), where fever and tachycardia may be attributed to infection rather than thyroid storm. 1
Clinical judgment must override the score when symptoms are severe—cases with scores as low as 50 points have presented with multiorgan dysfunction requiring aggressive intervention. 5
Extremely high scores (>70 points) are rare, with only 17 cases reported in the literature, but these represent the most severe presentations. 6
Immediate Management When Score Suggests Thyroid Storm
First-Line Treatment (Do Not Delay)
Administer propylthiouracil (PTU) as first choice because it inhibits both thyroid hormone synthesis and peripheral T4 to T3 conversion. 7, 8, 3
Give saturated potassium iodide solution or sodium iodide 1-2 hours AFTER starting thionamides—never before, as this worsens thyrotoxicosis. 7, 8, 3
Start beta-blockers (propranolol 60-80 mg orally every 4-6 hours, or esmolol infusion if hemodynamically unstable) to control tachycardia and cardiovascular symptoms. 8, 3
Administer dexamethasone or another corticosteroid to reduce peripheral T4 to T3 conversion and treat potential relative adrenal insufficiency. 8, 3
Supportive Care
Provide supplemental oxygen and position patient head-up. 3
Administer antipyretics for fever control. 7
Aggressive cooling measures may be needed for extreme hyperthermia (temperatures >41°C). 6
Identify and treat precipitating factors (infection, surgery, trauma, medication non-compliance). 7, 3
Special Situations
COVID-19 as Precipitating Factor
COVID-19 infection is a recognized precipitant of thyroid storm, causing both new-onset thyrotoxicosis and flare-ups of disease in remission. 1, 2
The BWPS may be particularly challenging to interpret in COVID-19 patients due to overlapping symptoms of fever and tachycardia. 1
Agranulocytosis Complicating Thyroid Storm
If agranulocytosis develops (from prior thionamide use) concurrent with thyroid storm, lithium can be used as an alternative to block thyroid hormone release. 2
Monitor for development of agranulocytosis with thionamide use throughout treatment. 7, 3
Pregnancy
- Treatment protocol is similar to non-pregnant patients, with monitoring of fetal status and avoidance of delivery during thyroid storm unless absolutely necessary. 7, 3
Monitoring Requirements
Hospitalize all patients with suspected thyroid storm, with severe cases requiring ICU admission. 8, 3
Monitor thyroid function every 2-3 weeks after initial stabilization. 8, 3
Watch for transition to hypothyroidism, which commonly occurs after thyroid storm treatment. 8, 3
Monitor for cardiac complications such as heart failure. 7, 3