The Burch-Wartofsky Point Scale — Scoring Suspected Thyroid Storm
A bedside point scale for suspected thyroid storm.
- 140: BWPS maximum score (summed across five domains)
- <25: Storm unlikely (points)
- 25–44: Impending storm (points)
- ≥45: Highly suggestive (points)
Why score before treating
Distinguishes true storm from severe thyrotoxicosis quickly.
Five scored domains
Temperature, CNS, GI/hepatic, cardiovascular, precipitant history combined.
Temperature Elevation and Central Nervous System Effects
Fever and mental status changes carry the heaviest weight.
- 30 pts: Temperature max (≥104°F (40°C))
- 30 pts: CNS effects max (agitation to coma)
- 10 pts: Mild CNS (agitation)
- 30 pts: Severe CNS (seizure or coma)
Temperature tiers
Points rise stepwise from 99°F to 104°F and above.
CNS severity tiers
Absent, mild, moderate, severe CNS disturbance each scored.
Cardiovascular Dysfunction and GI/Hepatic Involvement
Tachycardia, heart failure, and jaundice add substantial points.
- 25 pts: Tachycardia max (heart rate ≥140)
- 15 pts: CHF max (pulmonary edema)
- 10 pts: Atrial fibrillation (present)
- 20 pts: GI/hepatic max (jaundice)
Cardiovascular scoring
Heart rate, heart failure, and atrial fibrillation summed together.
GI/hepatic scoring
Nausea and vomiting score lower than unexplained jaundice.
Precipitating Event — The Trigger Behind the Crisis
A clear precipitant raises suspicion for true thyroid storm.
- 10 pts: Precipitant present (added to total)
- 0 pts: Precipitant absent (no addition)
- 4+: Common triggers (infection, surgery, DKA, labor)
- ~7%: Weight in total (of maximum score)
Identifying the trigger
Infection, surgery, trauma, or DKA often precede storm onset.
Why it matters
A trigger supports the diagnosis and guides concurrent treatment.
Total Score Interpretation — Guiding Treatment Urgency
The summed score sorts patients into three action tiers.
- <25: Storm unlikely (observe, treat cause)
- 25–44: Impending storm (close monitoring warranted)
- ≥45: Highly suggestive (aggressive storm therapy)
- 140: Score ceiling (theoretical maximum)
Reading the gauge
Needle position crosses three color-coded interpretation zones.
Clinical correlation required
High sensitivity, modest specificity — always correlate clinically.
BWPS point components at a glance