Burch-Wartofsky Point Scale (BWPS) for Thyrotoxicosis

Predicts likelihood of thyroid storm diagnosis in thyrotoxic patients.

Refer to the text below the scale for more information on the BWPS and its usage.


The Burch-Wartofsky Point Scale (BWPS) predicts likelihood of thyroid storm in adult patients with biochemical thyrotoxicosis. The scale consists in 7 specific signs and symptoms that are assigned a numerical value based on their severity.

The final score has three cut-off points for unlikely, impending and highly likely diagnosis.


BWPS score interpretation and next steps

BWPS Score Thyroid storm Next steps
<25 Unlikely diagnosis Investigate diagnosis of thyrotoxicosis and consider imaging
25 - 44 Impending diagnosis Consider ICU monitoring and symptom management
≥45 Diagnosis highly likely Consider rapid and aggressive multimodal management in ICU

1

Temperature °F (°C)

2

Heart Rate (beats/minute)

3

Congestive Heart Failure

4

Atrial fibrillation present

5

Central nervous system effects

6

Gastrointestinal-hepatic dysfunction

7

Precipitating event

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Burch-Wartofsky Point Scale (BWPS) Explained

The BWPS predicts likelihood of thyroid storm in adult patients with biochemical thyrotoxicosis. The scale consists in 7 specific signs and symptoms that are assigned a numerical value based on their severity.

The application of the scale can help clinicians discern between uncomplicated thyrotoxicosis, impending storm or established thyroid storm, where other measures, such as levels of T3 and T4 do not correlate with

The items in the BWPS assign points for dysfunction of thermoregulatory, GI, cardiovascular, and central nervous systems:

BWPS item Answer choices and points
Temperature °F (°C) <99 (<37.2) (0)
99–99.9 (37.2-37.7) (+5)
100–100.9 (37.8-38.2) (+10)
101–101.9 (38.3-38.8) (+15)
102–102.9 (38.9-39.2) (+20)
103–103.9 (39.3-39.9) (+25)
≥104.0 (≥ 40.0) (+30)
Heart Rate (beats/minute) <90 (0)
90-109 (+5)
110-119 (+10)
120-129 (+15)
130-139 (+20)
≥140 (+25)
Congestive Heart Failure Absent (0)
Mild (pedal edema) (+5)
Moderate (bibasilar rales) (+10)
Severe (pulmonary edema) (+15)
Atrial fibrillation present Yes (+10)
No (0)
Central nervous system effects Absent (0)
Mild (agitation) (+10)
Moderate (seizures, coma) (+20)
Severe (seizures, coma) (+30)
Gastrointestinal-hepatic dysfunction Absent (0)
Moderate (diarrhea, nausea/vomiting, abdominal pain) (+10)
Severe (unexplained jaundice) (+20)
Precipitating event Yes (+10)
No (0)

BWPS score interpretation and next steps

BWPS Score Thyroid storm Next steps
<25 Unlikely diagnosis Investigate diagnosis of thyrotoxicosis* and consider imaging
25 - 44 Impending diagnosis Consider ICU monitoring and symptom management
≥45 Diagnosis highly likely Consider rapid and aggressive multimodal management in ICU

Alternative thyrotoxicosis diagnosis include: Graves disease, toxic adenoma, subacute thyroiditis, toxic multinodular goiter, exogenous levothyroxine, struma ovarii)

Potential precipitant factors for the thyroid storm should also be investigated, such as: infection, medications (anesthetics, pseudoePHEDrine, amiodarone), thyroidal/nonthyroidal surgery, iodinated contrast exposure or exogenous thyroid hormone.

The BWPS was published following a retrospective analysis of patients diagnosed with thyroid storm and was validated retrospectively against the patients’ medical records.

Thyroid storm requires prompt treatment and hospitalization, often in ICUs and the main treatment strategies center around reducing production and release of thyroid hormone, reducing the effects of thyroid hormone on tissues, replacing fluid losses, and controlling temperature.

 

References

Original reference

Burch HB, Wartofsky L. Life-Threatening Thyrotoxicosis. Thyrotoxic storm. Endocrinology and Metabolism Clinics of North America . 1993; 22(2): 263-77.

Other references

Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am. 2006 Dec;35(4):663-86, vii.

Bahn Chair RS, Burch HB, Cooper DS, Garber JR, Greenlee MC, Klein I, Laurberg P, McDougall IR, Montori VM, Rivkees SA, Ross DS, Sosa JA, Stan MN; American Thyroid Association; American Association of Clinical Endocrinologists. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. 2011; 21(6):593-646.

Bahn RS, Burch HB, Cooper DS, Garber JR, Greenlee MC, Klein I, Laurberg P, McDougall IR, Montori VM, Rivkees SA, Ross DS, Sosa JA, Stan MN; American Thyroid Association; American Association of Clinical Endocrinologists. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Endocr Pract. 2011 May-Jun;17(3):456-520.


Specialty: Endocrinology

System: Endocrine

Objective: Diagnosis

No. Of Items: 7

Year Of Study: 1993

Abbreviation: BWPS

Article By: Denise Nedea

Published On: May 12, 2020

Last Checked: May 12, 2020

Next Review: May 12, 2025