Skip to Main Content


These remarkably powerful xenobiotics have evolved throughout history from essential weapons for hunting to critical adjuncts to modern anesthesia. Understanding the pharmacokinetics of the depolarizing and nondepolarizing neuromuscular blockers (NDNMBs) improves care in the emergency department, intensive care unit (ICU), and operating room. Understanding and early recognition of the complications of each NMB limit associated morbidity and mortality.


Curare is the generic term for the resinous arrowhead poisons used to paralyze hunted animals.100 The curare alkaloids are derived from the bark of the Strychnos vine, and the most potent alkaloids, the toxiferines, are derived from Strychnos toxifera. Fortunately for the hunters who used curare, ingestion of their prey did not cause paralysis. Sir Walter Raleigh discovered the use of curare in Guyana in 1595, and he was the first person to bring curare to Europe. The use of curare (d-tubocurarine) in anesthesia spanned almost 60 years and has been replaced by superior agents (with less histamine release and hypotension). Curare played a pivotal role in the discovery of the mechanism of neuromuscular transmission. In 1844, Claude Bernard placed a small piece of dry curare under the skin of a live frog and observed that the frog became limp and died.7 He performed an immediate autopsy and discovered that the heart was beating. Because direct muscle stimulation produced contraction but nerve stimulation did not, Bernard concluded that curare paralyzed the motor nerves. He later observed, however, that bathing the isolated nerve did not affect neuromuscular transmission, leading him to conclude: "Curare must act on the terminal plates of motor nerves."12 Curare was also used by Nobel Laureate physiologists Charles Sherrington, John Eccles, and Bernard Katz to further elucidate neuromuscular physiology. Its first clinical use was described in 1878 when Hunter used curare to treat patients with tetanus and seizures.100 In 1932, Raynard West used curare to reduce the muscular rigidity of hemiplegia.100


More recent nonmedical uses of succinylcholine have been less benign.2 The anesthesiologist Dr. Carl Coppolino was accused of murdering his wife in 1965 by succinylcholine injection.65 In 1983, shortly after Dr. Michael Swango began his internship at Ohio State University Hospital, patients began dying inexplicably, and he was relieved of his duties.92 After multiple residencies and jobs over 14 years, extending as far as Mnene Hospital in Zimbabwe, the prosecution secured Swango's guilty plea for the murder of three victims. The toxicologic analysis of the 7-year-old remains of Thomas Sammarco revealed succinylcholine in the liver and gallbladder and its metabolite succinylmonocholine in multiple organs which assisted in the conviction.


With the advent of new modalities of drug delivery, toxicologists must be attuned to possible malicious intent. Emergency personnel responding to a 911 call observed the widow removing an insulin pump reservoir from her dead husband's body with the stated intent to donate the costly equipment.4 A natural cause of death was presumed, yet surprisingly, forensic analysis revealed ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.


About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessEmergency Medicine Full Site: One-Year Subscription

Connect to the full suite of AccessEmergency Medicine content and resources including advanced 8th edition chapters of Tintinalli’s, high-quality procedural videos and images, interactive board review, an integrated drug database, and more.

$595 USD
Buy Now

Pay Per View: Timed Access to all of AccessEmergency Medicine

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.