🌡️ Thyroid Storm Recognition & Management (BWPS)
This tool applies the Burch-Wartofsky Point Scale (BWPS) to estimate the likelihood of thyroid storm and lays out a strictly sequenced treatment plan.
Clinical takeaway
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)
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When to use
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.
How it works
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.
Key points
- 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.
References
- Burch HB, Wartofsky L. Life-threatening thyrotoxicosis: thyroid storm. Endocrinol Metab Clin North Am 1993.
- Ross DS, et al. 2016 ATA Guidelines for Diagnosis and Management of Hyperthyroidism (thyroid storm). Thyroid 2016.
Decision support for licensed clinicians only; not a substitute for clinical judgement, diagnosis or local protocols.
Worked calculation
The values below come from this tool's own example placeholders and are computed server-side with the formula shown on this page, so the arithmetic can be checked quickly. It demonstrates how to substitute values only — it is not clinical advice and not a real case.
| Temperature | < 37.2°C |
|---|---|
| Heart rate (bpm) | < 99 |
| Atrial fibrillation | No |
| Congestive heart failure | None |
| Central nervous system | None |
| GI-hepatic | None |
| Precipitant | None |
→BWPS score0pts
- 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
| 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 |
→BWPS score140pts
- 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
Frequently asked questions
- What is Thyroid Storm Recognition & Management (BWPS)?
- This tool applies the Burch-Wartofsky Point Scale (BWPS) to estimate the likelihood of thyroid storm and lays out a strictly sequenced treatment plan.
- How is Thyroid Storm Recognition & Management (BWPS) calculated? What is the core formula?
- 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.
- When is Thyroid Storm Recognition & Management (BWPS) used?
- 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.
- What are the key clinical points for Thyroid Storm Recognition & Management (BWPS)?
- 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.
- What are the limits and cautions when using Thyroid Storm Recognition & Management (BWPS)?
- 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.
- How is Thyroid Storm Recognition & Management (BWPS) calculated in practice? Can you show a worked example?
- 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）