Background <p>Position changes in patients with thoracic spinal stab wounds may cause displacement of embedded sharp objects, increasing the risk of spinal cord or surrounding tissue injury. Management of these cases under anesthesia requires a carefully planned approach to minimize movement and ensure patient safety. </p> Case presentation <p>A 59-year-old Han Chinese male was admitted to the hospital due to “back pain and bleeding caused by stab wounds for 2 hours.” The patient was at high risk of secondary spinal cord injury and aspiration due to an embedded foreign object and a full stomach state. Fiberoptic bronchoscopy-guided endotracheal intubation was successfully performed in the prone position under mild sedation.</p> Conclusion <p>This case highlights the feasibility and safety of awake fiberoptic bronchoscopy-guided intubation in the prone position and provides valuable insights for managing similar high-risk scenarios in clinical practice.</p>