Background <p>Tracheobronchial injuries from blunt chest trauma carry high mortality, with complete thoracic inlet tracheal transection being previously undocumented. While Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) has been increasingly recognized as a critical airway support modality in traumatic tracheal reconstruction, current evidence provides no consensus regarding optimal ECMO initiation timing in surgical decision-making.</p> Case presentation <p>A 58-year-old male driver sustained front and back chest impacts in a crash. CT scan revealed complete tracheal transection at the thoracic inlet (mimicking a “bitten-off” appearance). With a dedicated VV-ECMO team on standby, we expeditiously commenced tracheal repair surgery. Intraoperatively, refractory oxygenation deterioration prompted immediate initiation of VV-ECMO via pre-positioned cannulas. Despite this intervention, the patient experienced a 2-minute cardiac arrest, which was successfully reversed. The procedure was ultimately completed with sustained VV-ECMO support, and the patient achieved satisfactory postoperative recovery.</p> Conclusions <p>This case demonstrates a unique traumatic tracheal injury mechanism and highlights the critical role of preemptive VV-ECMO team activation in managing complex airway reconstruction.</p>