1. Anticipated difficult intubation.

2. Anticipated cardiovascular collapse on induction of sedation or general anesthesia.

3. To isolate a lung leak or prevent contamination of lung segments by infected material (e.g. bronchopleural fistula or tracheo-esophageal fistula). Local anesthesia for orotracheal intubation

1. Local anesthetic spray (e.g. lidocaine (lignocaine) 4 per cent) to oropharynx and posterior tongue, in combination with advancing laryngoscope and 'spray as you go'. (Alternatively, a 100-mg benzocaine lozenge can be sucked 30 min before intubation, if this is feasible.)

2. Block the superior laryngeal nerve, which provides afferent innervation to the base of tongue, epiglottis, and laryngeal mucosa, as it pierces the thyrohyoid membrane. Displace the hyoid bone towards the side to be injected; a loss of resistance is felt once the thyrohyoid membrane is pierced. Inject 2 ml of local anesthetic (e.g. lidocaine 1 per cent) bilaterally just inferior to the greater cornu of the hyoid bone.

3. Puncture the cricothyroid membrane and inject 2 to 3 ml of 4 per cent lidocaine intratracheally. Correct placement is confirmed by aspiration of air before injection. Remove the needle as soon as injection is made, as the patient will cough and spread local anesthetic up into larynx.

Note that the maximum dose of lidocaine without epinephrine is 3 mg/kg.

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