What is the diagnostic and treatment approach for a patient with a history of Graves' disease suspected of having thyroid storm, using the Burch-Wartofsky (BW) score?

Burch-Wartofsky Score for Thyroid Storm

The Burch-Wartofsky Point Scale (BWPS) is a clinical scoring system used to diagnose thyroid storm, with scores ≥45 highly suggestive of thyroid storm, 25-44 suggesting impending storm, and <25 making thyroid storm unlikely. 1, 2, 3

Diagnostic Approach Using the Burch-Wartofsky Score

Clinical Assessment Components

The BWPS evaluates multiple organ systems to generate a total score out of 140 points 4:

• Thermoregulatory dysfunction: Fever is scored proportionally, with higher temperatures receiving more points 5
• Cardiovascular manifestations: Tachycardia out of proportion to fever, with additional points for atrial fibrillation or heart failure 5
• Central nervous system effects: Altered mental status ranging from mild agitation to seizures or coma 5
• Gastrointestinal-hepatic dysfunction: Presence of vomiting, diarrhea, or jaundice 5
• Precipitating event: Identification of a trigger such as infection, surgery, trauma, or medication non-compliance 5, 3

Score Interpretation

• ≥45 points: Highly suggestive of thyroid storm—initiate immediate treatment 1, 4
• 25-44 points: Impending thyroid storm—close monitoring and early intervention 1
• <25 points: Thyroid storm unlikely, but consider other causes of thyrotoxicosis 1

A critical caveat: Do not delay treatment while waiting for thyroid function test results if clinical suspicion is high. 5

Treatment Algorithm for Confirmed or Suspected Thyroid Storm

Immediate Resuscitation and Supportive Care

• Oxygen, IV fluids, and cooling measures for hyperthermia (avoid aspirin as it displaces thyroid hormone from binding proteins) 5
• Continuous cardiac monitoring and ICU-level care given high mortality risk 1, 2
• Treat precipitating factors aggressively (infection, trauma, surgery) 5

Multi-Drug Thyroid-Specific Therapy (Sequential Administration)

Step 1: Beta-blockade (unless severe heart failure present)

• Propranolol or atenolol for symptomatic relief and to block peripheral conversion of T4 to T3 5

Step 2: Thionamide therapy

• Propylthiouracil (PTU) or methimazole to block new thyroid hormone synthesis 5
• Exception: If agranulocytosis is present, lithium can be substituted 3

Step 3: Iodine therapy (given 1 hour AFTER thionamide)

• Saturated solution of potassium iodide (SSKI), sodium iodide, or Lugol's solution to block thyroid hormone release 5
• Critical timing: Never give iodine before thionamides, as it can worsen thyroid hormone synthesis 5

Step 4: Corticosteroids

• Dexamethasone to block peripheral T4 to T3 conversion and treat potential relative adrenal insufficiency 5

Step 5: Additional agents

• Cholestyramine to interrupt enterohepatic circulation of thyroid hormones 1
• Phenobarbital for severe agitation 5

Monitoring for Complications

Disseminated intravascular coagulation (DIC) occurs in approximately 23% of thyroid storm cases and correlates with higher BWPS scores and mortality. 2

• Monitor coagulation parameters, platelet count, and fibrinogen levels 2
• Higher APACHE II and SOFA scores predict need for intensive interventions (mechanical ventilation, dialysis, ECMO) 2

Special Populations

Pregnancy considerations:

• Thyroid storm carries high risk of maternal heart failure 5
• Use PTU over methimazole in first trimester 5
• Avoid delivery during active thyroid storm unless absolutely necessary 5
• Beta-blockers and supportive care remain first-line 5

Post-treatment:

• Endocrinology consultation for all cases 5, 1
• Consider definitive therapy (thyroidectomy or radioactive iodine) after stabilization to prevent recurrence 5

Common Pitfalls to Avoid

• Do not wait for laboratory confirmation before initiating treatment in clinically suspected cases 5
• Do not administer iodine before thionamides, as this can paradoxically worsen thyrotoxicosis 5
• Do not overlook DIC as a complication, particularly in patients with BWPS ≥60 2
• Do not use aspirin for fever control, as it increases free thyroid hormone levels 5