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Burch-Wartofsky Point Scale (BWPS) for Thyrotoxicosis

The Burch-Wartofsky Point Scale assesses one's risk for thyrotoxicosis. Thyrotoxicosis occurs when there is too much thyroid hormone in the body. The Burch-Wartofsky Point Scale incorporates a patient's temperature, gastrointestinal/hepatic/central nervous system symptoms, heart rate, congestive heart failure status, the presence of atrial fibrillation, and the presence of a precipitating event.
Temperature in °F (°C)
99-99.999-99.9 (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
CNS (Central nervous system) effects
Absent 0
Gentle (agitation) 10
Medium (coma, seizures) 20
Severe (coma, seizures) 30
Gastrointestinal-hepatic impairment
Absent 0
Medium(nausea/vomiting, diarrhea, abdominal pain) 10
Severe (unexplained jaundice) 20
Heart Pulse Rate (beats/minute)
90-109 5
110-119 10
120-129 15
130-139 20
≥140 25
CHF (Congestive Heart Failure)
Absent 0
Gentle (pedal edema) 5
Medium (bibasilar rales) 10
Acute (pulmonary edema) 15
AF (Atrial fibrillation) presence
No 0
Yes 10
Precipitating event
No 0
Yes 10


Measured Factor
Burch-Wartofsky Point Scale
Measured Factor Disease
  • Likelihood of thyroid storm occurence in the future or presence
Measured Factor Detail
The Burch-Wartofsky Point Scale determines a patient's risk for thyrotoxicosis. Thyrotoxicosis results from excess thyroid hormone in an individual's body. Thyrotoxicosis can also be referred to as a "thyroid storm." During a "thyroid storm," a patient's blood pressure, heart rate, and temperature can reach potentially fatal values.
Body System
Measured Factor Low Impact
  • A BWPS less than 25 represents a thyroid storm being unlikely.
Measured Factor High Impact
  • A BWPS 25-44 represents a thyroid storm may occur in the future. A BWPS greater than or equal to 45 represents a thyroid storm presently occuring.
  • N/A

Result Interpretation

Ranges Ranges
  • Critical Low: N/A
  • Critical High: > or equal to 45 points
  • Normal: <25 points
  • Normal Adult Male: <25 points
  • Normal Adult Female: <25 points
  • Normal Pediatric: <25 points
  • Normal Neonate Female: N/A
  • Normal Geriatric Male: <25 points
  • Normal Geriatric Female: <25 points
Result Low Conditions
  • N/A
Result High Conditions
  • Hyperthyroidism
False Positive
  • Fever
  • tachycardia
  • epilepsy
  • jaundice
  • pulmonary edema
References: 2
Test Limitations
References: 2


Study Validation 1
The aim of this study was to describe features of a thyroid storm and risk factors associated with mortality. 

Between 2006 and 2011, a retrospective review in one hospital identified 28 cases of thyroid storm. Thyroid storm was thought to be precepted by noncompliance to treatment and infection. Cardiac symptoms such as tachycardia and atrial fibrillations were seem a majority of the patients with thyroid storm. Neuropsychological presentations corelated with increased mortality. Mortality rate was 25%.
References: 3
Study Validation 2
A thyroid storm is associated with morbidity and mortality, making it an endocrine emergency. Some type of event typically converts this patient into this sort of thyrotoxicosis. Thionamides, iodine, beta-adrenergic receptor antagonists, corticosteroids, and supportive therapy are used in treatment. After the storm is subsides, thyrotoxicosis treated should be planned and initiated.
References: 4
Study Validation 3
Thyroid storm was surveyed in Japan. This study defined thyroid storm and created diagnostic criteria for the endocrine emergency. 99 patients were used from the literature in addition to 7 patients from the surveys to create diagnostic criteria. Thyroid storm had to include thyrotoxicosis and a combination of nervous system symptoms, fever, tachycardia, heart failure, gastrointestinal/hepatic symptoms, and a serum bilirubin concentration greater than 3. 

282 patients were found to have thyroid storm 1, thyroid storm with thyrotoxicosis. 74 patients were found to have thyroid storm 2, thyroid storm without thyrotoxicosis.  The most common cause of death in both types of thyroid storms were multiorgan failure.
References: 5
Study Additional 1
Thyroidectomy is the treatment of choice for individuals with thyroid storm. However, cardiopulmonary diseases may not make a patient an ideal surgical candidate. 

This study retrospectively analyzed the outcomes of 10 older individuals who underwent thyroidectomy because of thyroid storm. All patients survived the thyroidectomy with the two oldest patients dying 2-3 weeks after the procedure. A 10% mortality rate was found for all patients who underwent thyroidectomy regardless of co-morbidities. Thyroidectomy should be considered as the treatment for thyroid storm even in older patients with co-morbidities.
References: 6
Study Additional 2
References: 2
Study Additional 3
References: 2


Henry Burch
MD, National Naval Medical Center in Bethesda, Maryland, Endocrinologist


  1. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am. 1993 Jun;22(2):263-77.
  2. N/A
  3. Swee du S, Chng CL, Lim A. Clinical characteristics and outcome of thyroid storm: a case series and review of neuropsychiatric derangements in thyrotoxicosis. Endocr Pract. 2015 Feb;21(2):182-9. doi: 10.4158/EP14023.OR.
  4. Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am. 2006 Dec;35(4):663-86, vii.
  5. Akamizu T, Satoh T, Isozaki O, Suzuki A, Wakino S, Iburi T, Tsuboi K, Monden T, Kouki T, Otani H, Teramukai S, Uehara R, Nakamura Y, Nagai M, Mori M; Japan Thyroid Association. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid. 2012 Jul;22(7):661-79. doi: 10.1089/thy.2011.0334.
  6. Scholz GH, Hagemann E, Arkenau C, Engelmann L, Lamesch P, Schreiter D, Schoenfelder M, Olthoff D, Paschke R. Is there a place for thyroidectomy in older patients with thyrotoxic storm and cardiorespiratory failure? Thyroid. 2003 Oct;13(10):933-40.

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