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Thyroid storm

Updated May 21, 2025

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of thyroid storm are prepared by our editorial team based on guidelines from the American Society for Apheresis (ASFA 2019), the European Thyroid Association (ETA 2018), the American Thyroid Association (ATA 2016), and the Japan Thyroid Association (JTA/JES 2016).

Screening and diagnosis

Diagnostic criteria

As per ATA 2016 guidelines:

Diagnose thyroid storm clinically in a severely thyrotoxic patient with evidence of systemic decompensation.

Consider using a sensitive diagnostic system (such as the Burch-Wartofsky Point Scale) as an adjunct to diagnosis.

Burch-Wartofsky Point Scale for thyroid storm (BWPS)

Calculator

When to use

Temperature, degrees C [degrees F]

< 37.2 [< 99]

37.2-37.7 [99-99.9]

37.8-38.2 [100-100.9]

38.3-38.8 [101-101.9]

38.9-39.2 [102-102.9]

39.3-39.9 [103-103.9]

≥ 40.0 [≥ 104.0]

Heart rate, bpm

< 90

90-109

110-119

120-129

130-139

≥ 140

Congestive heart failure

Absent

Mild

Moderate

Severe

Atrial fibrillation

Yes

Central nervous system disturbance

Absent

Mild: agitation

Moderate: delirium, psychosis, extreme lethargy

Severe: seizure, coma

Gastrointestinal-hepatic dysfunction

Absent

Moderate

Severe

Precipitating event

Yes

Calculation

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The Burch-Wartofsky Point Scale (BWPS) is a clinical scoring system used to diagnose thyroid storm, a severe and potentially life-threatening complication of hyperthyroidism. This calculator is applicable to patients presenting with symptoms suggestive of a thyroid storm, such as fever, tachycardia, altered mental status, and gastrointestinal symptoms. The BWPS assesses the likelihood of a thyroid storm based on the presence and severity of various clinical manifestations, including thermoregulatory dysfunction, central nervous system effects, gastrointestinal-hepatic dysfunction, cardiovascular dysfunction, and precipitating events. The clinical utility of the BWPS is to aid in the early recognition and treatment of thyroid storm, thereby reducing associated morbidity and mortality. It can also help guide the intensity of treatment and need for hospitalization. There are no specific exclusion criteria for the use of the BWPS. However, it should be noted that this scale is not definitive and should be used in conjunction with other clinical findings and laboratory tests. It may not be as useful in patients with atypical presentations or those with concurrent illnesses that can mimic the symptoms of a thyroid storm.

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Classification and risk stratification

Risk stratification: as per ATA 2016 guidelines, risk stratify patients using a validated scale. Patients with a Burch-Wartofsky Point Scale of ≥ 45 and evidence of systemic decompensation require aggressive therapy. The decision to use aggressive therapy in patients with a Burch-Wartofsky Point Scale of 25-44 should be based on clinical judgment.

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Medical management

Setting of care: as per JES/JTA 2016 guidelines, transfer patients with highly suspected thyroid storm based on diagnostic criteria to a general hospital with an ICU and specialists in endocrinology and other subspecialties.

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Therapeutic procedures

Plasmapheresis: as per JES/JTA 2016 guidelines, consider performing therapeutic plasma exchange if clinical improvement is not noted within 24-48 hours of initial treatment with appropriate doses of antithyroid drugs, inorganic iodine, corticosteroids, or β-blockers, as well as specific treatment for the triggering disease and complications with thyroid storm.

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Preventative measures

Prevention

As per JES/JTA 2016 guidelines:

Take care to prevent thyroid storm in patients with poor adherence undergoing antithyroid drug treatment.

Consider offering definitive treatment of Graves' disease, either by radioactive iodine or thyroidectomy, to prevent recurrent thyroid storm in patients successfully managed during the acute stage of thyroid storm.

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