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 |
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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 · 12:00 AM
Last Checked: May 12, 2020
Next Review: May 12, 2025