Thyroid Storm Recognition & Management (BWPS) — free guideline decision tool

This tool applies the Burch-Wartofsky Point Scale (BWPS) to estimate the likelihood of thyroid storm and lays out a strictly sequenced treatment plan.

BWPS sums temperature, heart rate, atrial fibrillation, heart failure, CNS, GI-hepatic, and precipitant points. Storm management order: PTU → iodine (≥ 1 h later) → glucocorticoid → β-blocker → supportive care; plasma exchange if refractory.

Use when thyrotoxicosis is severe: a BWPS ≥ 45 suggests storm, 25–44 is impending, and < 25 is unsupportive — but treatment is driven by clinical judgment, not by waiting for a threshold.

Inorganic iodine must be given at least an hour after the antithyroid drug, or it can fuel hormone synthesis instead of blocking release. (original synthesis · not guideline verbatim) Propranolol is avoided in severe heart failure, where a β1-selective agent or esmolol is used. Glucocorticoids both treat the storm and guard against concurrent adrenal crisis.

For licensed clinicians and clinical researchers. Interpret results with history, investigations and local protocols; not a diagnosis or prescription, and not a substitute for multidisciplinary decision-making or local guidelines.

Inputs: Temperature < 37.2°C, Heart rate (bpm) < 99, Atrial fibrillation No, Congestive heart failure None, Central nervous system None, GI-hepatic None, Precipitant None → Result: BWPS score 0 pts（Decision: Does not support thyroid storm (< 25 unsupportive / 25–44 impending / ≥ 45 storm), Management: Below the storm threshold: manage as hyperthyroidism/thyrotoxicosis per protocol with close monitoring, watching for progression to storm; actively remove/treat precipitants, Key point: Iodine must be given after ATD (≥ 1 h), otherwise it may worsen; propranolol is contraindicated in severe heart failure; glucocorticoid also guards against adrenal crisis） Inputs: Temperature ≥ 40°C, Heart rate (bpm) ≥ 140, Atrial fibrillation Yes, Congestive heart failure Severe (pulmonary edema), Central nervous system Severe (seizure/coma), GI-hepatic Severe (jaundice), Precipitant Present → Result: BWPS score 140 pts（Decision: Suggestive of thyroid storm (< 25 unsupportive / 25–44 impending / ≥ 45 storm), Management: Manage as storm (mind the order): (1) ATD, prefer PTU (~600 mg/d, max 1600) to block synthesis; (2) 1 hour after ATD, give inorganic iodine (Lugol's 4–8 drops q6–8h PO) to block release; (3) glucocorticoid (hydrocortisone 50–100 mg q6–8h IV); (4) β-blocker for rate control (propranolol 60–80 mg q4–6h; propranolol contraindicated in severe heart failure, use β1-selective/esmolol); (5) cooling (avoid aspirin), fluids, correct electrolytes, sedation, treat precipitant (e.g. infection); if refractory → plasma exchange, Key point: Iodine must be given after ATD (≥ 1 h), otherwise it may worsen; propranolol is contraindicated in severe heart failure; glucocorticoid also guards against adrenal crisis）