Burch-Wartofsky Score Calculator (Thyroid Storm)
Burch-Wartofsky Score Calculator (Thyroid Storm)
Score the degree of systemic decompensation in suspected thyroid storm — a clinical diagnosis that biochemistry alone cannot make.
Burch-Wartofsky Score (Thyroid Storm)
7 items → 0–140Temperature 38.9–39.4°C (20), mild agitation (10), moderate GI symptoms (10), heart rate 120–129 (15), no CHF (0), no AF (0), positive precipitant history (10)
Scoring
- ≥ 45
- highly suggestive of thyroid storm
- 25 – 44
- suggestive of impending storm
- < 25
- storm unlikely
Worked example
Temperature 38.9–39.4°C (20), mild agitation (10), moderate GI symptoms (10), heart rate 120–129 (15), no CHF (0), no AF (0), positive precipitant history (10)
20 + 10 + 10 + 15 + 0 + 0 + 10 = 65 points
65 is 45 or above → thyroid storm likely
Interpreting the total
| Score | Interpretation | Action |
|---|---|---|
| < 25 | Storm unlikely | Treat underlying thyrotoxicosis; keep reassessing if the patient deteriorates |
| 25 – 44 | Impending storm | Treat aggressively; do not wait for a higher score |
| ≥ 45 | Storm likely | Begin storm treatment immediately, without waiting for thyroid function results |
A score to prompt treatment, not withhold it
Thyroid storm is a clinical diagnosis. There is no biochemical test that confirms it, because free T4 and free T3 concentrations in storm are similar to those in uncomplicated, severe thyrotoxicosis — the two conditions are not reliably distinguished by the degree of biochemical abnormality. What separates them is the degree of systemic decompensation: fever, central nervous system disturbance, gastrointestinal and hepatic dysfunction, tachycardia, heart failure, atrial fibrillation, and a precipitating event. The Burch-Wartofsky score converts that clinical picture into a number precisely because the biochemistry cannot do the job.
The score’s deliberate bias is toward sensitivity over specificity. It was built to identify a life-threatening emergency with a reported mortality of 10 to 30% even with treatment, so it is weighted to flag possible storm rather than to withhold treatment until certainty is reached. A score of 45 or more should prompt starting definitive therapy — beta-blockade, a thionamide, iodine given after the thionamide, and corticosteroids — immediately, without waiting for thyroid function tests to return, since those results will not distinguish storm from severe thyrotoxicosis in any case and the delay itself carries risk.
The Japanese Thyroid Association has published an alternative, stricter set of diagnostic criteria for thyroid storm, built around defined combinations of thermoregulatory, cardiovascular, gastrointestinal-hepatic and central nervous system findings rather than a single additive score. It is used more widely in some regions and produces a somewhat different sensitivity-specificity balance; clinicians working across systems should recognise that a patient meeting one set of criteria and not the other does not resolve the underlying clinical judgement the diagnosis still requires.
Frequently asked questions
What Burch-Wartofsky score indicates thyroid storm?
A score of 45 or above is highly suggestive of thyroid storm. Between 25 and 44 is suggestive of impending storm and should prompt aggressive treatment. Below 25 makes storm unlikely.
Does thyroid function testing confirm or exclude thyroid storm?
No. Free T4 and free T3 levels are similar in storm and in uncomplicated severe thyrotoxicosis. The diagnosis rests on the degree of systemic decompensation, which is what this score measures, not on the biochemistry.
Should treatment wait for a score of 45 or more?
No. In a patient with a suggestive clinical picture, treatment should begin without waiting for thyroid function results, since biochemistry will not distinguish storm from severe thyrotoxicosis and delay carries real risk given the mortality of untreated storm.
What is the alternative to the Burch-Wartofsky score?
The Japanese Thyroid Association criteria are a stricter, combination-based alternative used widely in some regions. They can classify a patient differently from the Burch-Wartofsky score, and neither replaces overall clinical judgement.
Related calculators
References
- Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am. 1993;22(2):263–77.
- Ross DS et al. 2016 American Thyroid Association Guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid. 2016;26(10):1343–421.