CASE PRESENTATION: A 29-year-old male ejected in an MVA presented to a regional hospital and was intubated for unresponsiveness. He had cardiac arrest and underwent emergent left thoracotomy and aortic cross clamping with return of spontaneous circulation. Imaging revealed a lacerated horseshoe kidney with hemorrhage and multiple fractures. He developed worsening ARDS on maximal ventilator settings and was transferred for ECMO. On arrival, he underwent thoracic exploration, exploratory laparotomy, splenectomy, and abdominal closure. Initial flexible bronchoscopy showed no evidence of bleeding. Blood was later noted on endotracheal tube suctioning; systemic heparin for ECMO was discontinued. Flexible bronchoscopy revealed extensive tracheal clot occluding the ET tube and extending past the carina. Attempts at saline lavage, suctioning, and forceps removed small clots, but a large burden remained. Nebulized heparin was initiated to prevent further clots. tPA in 5 mL aliquots was directly applied to each clot site and allowed to settle for 24 hours, after which liquefied clot was removed via suction through the flexible bronchoscope. This process was repeated four times during his hospital course with eventual complete removal of the blood clot.