Assessing the Burch-Wartofsky Score for Thyroid Storm
The Burch-Wartofsky Point Scale (BWPS) is a quantitative scoring system that assigns points across five clinical categories—thermoregulatory dysfunction, cardiovascular effects, central nervous system manifestations, gastrointestinal-hepatic dysfunction, and precipitating events—with a score ≥45 points highly suggestive of thyroid storm and requiring immediate aggressive treatment. 1, 2
Clinical Categories and Point Assignment
1. Thermoregulatory Dysfunction (Temperature)
- 37.2-37.7°C (99-99.9°F): 5 points
- 37.8-38.2°C (100-100.9°F): 10 points
- 38.3-38.8°C (101-101.9°F): 15 points
- 38.9-39.4°C (102-102.9°F): 20 points
- 39.4-39.9°C (103-103.9°F): 25 points
- ≥40°C (≥104°F): 30 points
Fever is a cardinal feature, with rates significantly higher in thyroid storm patients compared to compensated thyrotoxicosis 2.
2. Cardiovascular Dysfunction
Tachycardia (heart rate >100 bpm is significantly more common in thyroid storm): 2
- 99-109 bpm: 5 points
- 110-119 bpm: 10 points
- 120-129 bpm: 15 points
- 130-139 bpm: 20 points
- ≥140 bpm: 25 points
Atrial fibrillation: 10 points
Congestive heart failure:
- Mild (pedal edema): 5 points
- Moderate (bibasilar rales): 10 points
- Severe (pulmonary edema): 15 points
3. Central Nervous System Effects
This is the most discriminating clinical feature distinguishing true thyroid storm from severe thyrotoxicosis: 2
- Absent: 0 points
- Mild (agitation): 10 points
- Moderate (delirium, psychosis, extreme lethargy): 20 points
- Severe (seizures, coma): 30 points
Altered mentation was the only clinical feature significantly different between clinically diagnosed thyroid storm and patients meeting BWPS criteria but without storm 2. Thyrotoxic patients with central nervous system dysfunction derive the greatest benefit from aggressive thyroid storm-specific treatment. 2
4. Gastrointestinal-Hepatic Dysfunction
- Moderate (diarrhea, nausea/vomiting, abdominal pain): 10 points
- Severe (unexplained jaundice): 20 points
5. Precipitating Event
- Present: 10 points
- Absent: 0 points
Common precipitants include infection (notably COVID-19), diabetic ketoacidosis, surgery, trauma, or medication non-compliance 1, 3. The presence of a precipitating event is significantly more common in thyroid storm than compensated thyrotoxicosis 2.
Score Interpretation
- <25 points: Thyroid storm unlikely
- 25-44 points: Impending thyroid storm; consider aggressive treatment
- ≥45 points: Thyroid storm highly likely; initiate immediate aggressive treatment 1, 2, 3
A score of 60 or higher is highly suggestive of thyroid storm and mandates emergency intervention. 1
Critical Clinical Pearls
Diagnostic Pitfalls
Thyroid storm can be masked by concurrent conditions such as diabetic ketoacidosis, which may obscure thyrotoxic symptoms 3. When treating DKA, persistent tachycardia and altered mentation despite correction of hyperglycemia should raise suspicion for thyroid storm 3.
Laboratory confirmation is not required before treatment. Thyroid storm is a clinical diagnosis; do not delay treatment waiting for thyroid function tests 2. However, expect TSH <0.01 mIU/L with markedly elevated free T4 and T3 1, 3.
Immediate Management Considerations
All thyroid storm patients should receive multi-modal therapy within 24 hours: thionamides, beta-blockade, glucocorticoids, and iodides 2. However, agranulocytosis from antithyroid drugs precludes their use; lithium is an alternative in this scenario 1.
Beta-blockers may be contraindicated in low cardiac output states such as severe pulmonary hypertension with obstructive shock 4. In such cases, focus on other thyroid storm therapies and hemodynamic support.
Multiorgan Dysfunction
Thyroid storm can present with acute liver failure, acute kidney injury, lactic acidosis, heart failure, coagulopathy, and rhabdomyolysis 5. A BWPS score of 50 can still represent thyroid storm when accompanied by severe multiorgan dysfunction 5.