Burch-Wartofsky Point Scale (BWPS) for Thyrotoxicosis
Why Use
Can help distinguish uncomplicated thyrotoxicosis from “impending” storm or established thyroid storm.
When to Use
Patients with thyrotoxicosis in the setting of systemic decompensation.
Formula
Pearls / Pitfalls
The Burch-Wartofsky Point Scale (BWPS) is a quantitative diagnostic tool based on 3 major observations in patients with thyroid storm: Continuum of end organ dysfunction. High variability of symptoms and signs between patients. High mortality associated with missed diagnosis. Assigns points for dysfunction of thermoregulatory, GI, cardiovascular, and central nervous systems. Given the high mortality/morbidity associated with thyroid storm, the BWPS intentionally utilizes liberal criteria, which may also lead to false-positives. Elderly patients may present with apathetic thyrotoxicosis with atypical symptoms (weakness, memory loss, obtundation, cardiac failure). Serum levels of T4 and T3 do NOT correlate with severity of thyrotoxicosis. Presence of jaundice suggests especially poor prognosis. Ultimately, thyroid storm is a clinical diagnosis and requires prompt recognition and treatment.
Management
Search for potential precipitant(s) of thyroid storm: infection, thyroidal/nonthyroidal surgery, medications (anesthetics, pseudoePHEDrine, amiodarone), iodinated contrast exposure, DKA, exogenous thyroid hormone, CVA, MI, PE. Target treatment towards thyroid hormone formation, release, and adrenergic action: Anti-thyroid drug therapy (propylthiouracil, methIMAzole). Potassium iodine. Beta-blockade (propranolol, esmolol). Corticosteroid (hydrocortisone). Supportive care (fluids, acetaminophen). ICU level care.
Critical Actions
Iodine therapy should be administered at least 1 hour AFTER thionamides to prevent stimulation of new thyroid hormone synthesis. Avoid aspirin because it displaces T4 from thyroid binding globulin, resulting in increase of free T4. TItrate beta blockers carefully as excessive doses in thyrotoxic patients can cause cardiovascular collapse. Besides reducing T4 to T3 conversion, steroids provide adrenal support, which can be impaired in thyroid storm.
Advice
BWPS ≥45 is highly suggestive of thyroid storm; consider rapid and aggressive multimodal management in ICU. BWPS 25-44 suggests impending thyroid storm; consider thionamides, symptom management. Consider ICU monitoring. BWPS <25 is unlikely to represent thyroid storm; investigate diagnosis of thyrotoxicosis (Graves disease, toxic adenoma, toxic multinodular goiter, subacute thyroiditis, exogenous levothyroxine, struma ovarii) and obtain additional imaging (thyroid ultrasound, radioactive iodine uptake and scan).
More Information
Score interpretation: Score Thyroid Storm <25 Unlikely to represent thyroid storm 25-44 Suggestive of impending thyroid storm ≥45 Highly suggestive of thyroid storm