Endocrinology
Burch-Wartofsky Score
Likelihood of thyroid storm.
Education and reference only. Not a substitute for clinical judgement, local policy or product labelling. Always verify before clinical use. Values are calculated in your browser and never stored.
Background
The Burch-Wartofsky Point Scale estimates the likelihood that a thyrotoxic patient is in, or approaching, thyroid storm — a life-threatening decompensation of hyperthyroidism. It assigns weighted points across several domains: temperature, central nervous system effects, gastrointestinal/hepatic dysfunction, heart rate, presence of congestive heart failure, atrial fibrillation and a precipitating event. The points reflect how strongly each feature is associated with storm, with severe central nervous system disturbance and very high temperature or heart rate scoring most. It was designed as an aid to recognising a condition that has no single diagnostic test.
Interpreting the result
A total below 25 makes thyroid storm unlikely, 25–44 suggests impending storm, and 45 or above is highly suggestive of thyroid storm. The score is deliberately weighted towards over-recognition, because missing storm is far more dangerous than over-treating. It supports clinical judgement rather than replacing it: a high score in a thyrotoxic patient demands urgent treatment without waiting for confirmation. Thyroid function tests do not distinguish storm from uncomplicated thyrotoxicosis, which is why a clinical score is used.
Worked example
A thyrotoxic patient has a temperature of 39 °C (+20), agitation and confusion (moderate CNS, +20), a heart rate of 135 (+20), atrial fibrillation (+10) and a clear precipitant of recent infection (+10), giving a total of 80 — highly suggestive of thyroid storm and a medical emergency.
Critical actions
Thyroid storm is a medical emergency — treat clinically; do not wait for the score. A score ≥45 is highly suggestive.
Pearls / pitfalls
- Thyroid storm is a clinical emergency — treat on suspicion and do not wait for the score or for thyroid function results.
- The scale is intentionally biased towards sensitivity, so an intermediate score should still prompt close monitoring and a low threshold to treat.
- Thyroid function tests cannot distinguish storm from uncomplicated thyrotoxicosis, which is exactly why the score exists.
- Always look for and address the precipitant, such as infection, surgery or non-adherence to treatment.
Evidence & validation
Proposed by Burch and Wartofsky in 1993 as an empirically weighted clinical scale; it is widely used and is referenced in endocrine society guidance on the management of thyrotoxicosis, always as an adjunct to clinical assessment.
Frequently asked questions
What Burch-Wartofsky score indicates thyroid storm?
A score of 45 or more is highly suggestive of thyroid storm, 25–44 suggests impending storm, and below 25 makes it unlikely. However, treatment is driven by clinical suspicion, not the number alone.
Should I wait for the score before treating?
No. Thyroid storm is a medical emergency with high mortality if untreated. If the clinical picture is convincing, urgent treatment should begin immediately, in parallel with calculating the score and obtaining tests.
Can blood tests confirm thyroid storm?
Not reliably. Thyroid function tests in storm overlap with those of uncomplicated thyrotoxicosis, so they confirm hyperthyroidism but cannot diagnose storm. The diagnosis is clinical, which is why the Burch-Wartofsky scale was developed.
Why is the score weighted towards over-diagnosis?
Because failing to recognise thyroid storm is far more dangerous than over-treating, the scale is deliberately sensitive. An intermediate score should not be falsely reassuring and warrants close observation and a low threshold to treat.
Why does identifying a precipitant matter?
Storm is usually triggered by an event such as infection, surgery, trauma or stopping antithyroid treatment. Identifying and treating the precipitant is a key part of management, and a known trigger also adds to the score.
References
- Burch HB, Wartofsky L. Life-threatening thyrotoxicosis: thyroid storm. Endocrinol Metab Clin North Am. 1993;22(2):263–277.
- Ross DS, Burch HB, Cooper DS, et al. American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid. 2016.
About the creator
Burch HB, Wartofsky L
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