Explosive and Incendiary Devices and Hostile Mass-casualty Attacks Practice Questions

25 multiple-choice questions on Explosive and incendiary devices and hostile mass-casualty attacks for paramedic and EMT students, from Chapter 51 (Terrorism Response). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. A homemade bomb built from a pressure cooker packed with nails and ball bearings, as in the 2013 Boston Marathon attack, is classified as:

   1. A. A military-grade landmine
   2. B. An improvised explosive device
   3. C. A radiological dispersal device
   4. D. An incendiary firebomb
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   Answer: B. An improvised explosive device

   An improvised explosive device (IED) is any homemade bomb, often built from everyday containers and packed with shrapnel. A radiological dispersal device would contain radioactive material, which these bombs did not.

2. At a ground-level bombing in a standing crowd, such as the 2013 Boston Marathon, the most common severe injuries are:

   1. A. Isolated head injuries from falls
   2. B. Upper airway burns from hot gases
   3. C. Leg wounds and traumatic amputations
   4. D. Spinal cord injuries from blast wind
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   Answer: C. Leg wounds and traumatic amputations

   A device on the ground drives fragments and blast forces into the legs of people standing nearby, causing mangled limbs and amputations. Airway burns occur mainly in enclosed spaces with fire, not open-air street bombings.

3. A key prehospital lesson from the 2013 Boston Marathon bombing was that:

   1. A. Early tourniquets saved many lives
   2. B. Tourniquets caused most amputations
   3. C. Bystanders should not touch victims
   4. D. Patients should go to a single hospital
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   Answer: A. Early tourniquets saved many lives

   Rapid tourniquet use by responders and bystanders, followed by spreading patients among several trauma centers, was credited with a very low death rate among hospitalized victims. The amputations were caused by the blast, not by tourniquets.

4. A woman who was near a suicide bomber has a fragment of bone from the bomber embedded in her arm. Besides wound care, the hospital will consider:

   1. A. Rabies post-exposure treatment
   2. B. Hepatitis B and tetanus protection
   3. C. Treatment for lead poisoning
   4. D. Steroids for a reaction to bone
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   Answer: B. Hepatitis B and tetanus protection

   Biologic shrapnel from a bomber can carry bloodborne pathogens, so CDC guidance includes hepatitis B vaccination and tetanus protection for victims with penetrating wounds or mucous membrane exposure. Rabies is spread by animal bites, not human tissue fragments.

5. TATP, used in several suicide bombings in Europe, is a concern because it is:

   1. A. A military plastic explosive
   2. B. A slow-burning propellant
   3. C. Easy to spot by its blue color
   4. D. Homemade and highly unstable
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   Answer: D. Homemade and highly unstable

   Triacetone triperoxide is made from common chemicals and can detonate from heat, friction, or shock, endangering bomb makers and responders. Plastic explosives such as C-4 are military products and are far more stable.

6. A vehicle-borne IED requires a much larger evacuation distance than a pipe bomb because it:

   1. A. Burns for longer after it explodes
   2. B. Usually carries radioactive material
   3. C. Can carry a much larger charge
   4. D. Is harder to see from the air
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   Answer: C. Can carry a much larger charge

   A car or truck can carry hundreds or thousands of pounds of explosive, so its blast and fragment range is far greater. The size of the charge, not burn time, sets the safe distance.

7. Police find a suspected pipe bomb at a stadium entrance and set an evacuation perimeter. EMS should stage:

   1. A. Outside the perimeter police have set
   2. B. Just behind the nearest parked car
   3. C. At the perimeter tape for fast access
   4. D. Upwind of the device, about 30 m away
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   Answer: A. Outside the perimeter police have set

   Staging outside the bomb squad's perimeter, behind solid cover and away from glass, protects crews if the device detonates. A parked car is tempting cover but can become a source of fragments, and it may itself be a second device. Staging right at the tape leaves no margin if the perimeter has to grow, and 30 m is well inside the outdoor evacuation distance of about 366 m (1,200 ft) suggested for a pipe bomb.

8. A bottle filled with gasoline and fitted with a burning rag is an example of:

   1. A. A high-order explosive
   2. B. An incendiary device
   3. C. A chemical nerve weapon
   4. D. A pressure-wave bomb
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   Answer: B. An incendiary device

   Incendiary devices such as Molotov cocktails are designed to start fires rather than create a blast wave. High-order explosives produce a supersonic pressure wave, which a gasoline bottle does not.

9. Burns from incendiary materials such as thermite or napalm-like gels are especially deep because the material:

   1. A. Releases cyanide on contact with skin
   2. B. Reacts with sweat to form acid
   3. C. Sticks to the skin and burns very hot
   4. D. Penetrates deep through blast force
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   Answer: C. Sticks to the skin and burns very hot

   Gelled fuels cling to skin and thermite burns at extremely high temperatures, causing full-thickness burns. Smoke from the fire can contain cyanide, but the depth of the burn comes from the adherent, hot material. The heat comes from the burning material itself; it does not react with sweat to form an acid, and incendiaries spread fire rather than driving material deep with blast force.

10. An incendiary device is thrown into a crowded nightclub. Besides burns, the injuries you should expect most are:

    1. A. Primary blast lung and ear injury
    2. B. Penetrating wounds from fragments
    3. C. Delayed chemical burns to the skin
    4. D. Smoke inhalation and crush at the exits
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    Answer: D. Smoke inhalation and crush at the exits

    Incendiary attacks in enclosed spaces kill mainly through smoke and toxic gases and through crowd crush as people rush the exits, as past nightclub fires have shown. There is little or no pressure wave, so primary blast injury is unlikely.

11. Fifteen minutes after a bomb explodes downtown, gunmen open fire in a hotel lobby across town. This pattern is typical of:

    1. A. A copycat attack by a stranger
    2. B. A complex coordinated attack
    3. C. Two random unrelated crimes
    4. D. A hostage negotiation in progress
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    Answer: B. A complex coordinated attack

    Complex coordinated attacks, such as Mumbai in 2008 and Paris in 2015, strike several sites in sequence, often with guns, bombs, and fire. Treating the events as unrelated delays the protective steps the region needs.

12. During a complex coordinated attack, the EMS commander should:

    1. A. Hold resources in reserve for new sites
    2. B. Send the available units to the first site
    3. C. Close the hospitals to new patients
    4. D. Wait until police clear the whole city
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    Answer: A. Hold resources in reserve for new sites

    Attackers may strike more targets, so commanders keep units in reserve and spread the load rather than committing everything to the first scene. Sending every unit to one site leaves the region unable to respond to the next attack.

13. A truck drives into a crowd at a holiday market. The injury pattern you should expect is mainly:

    1. A. Mostly penetrating gunshot wounds
    2. B. Minor abrasions and ankle sprains
    3. C. Blunt trauma and crush injuries
    4. D. Inhalation burns from burning fuel
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    Answer: C. Blunt trauma and crush injuries

    Vehicle-ramming attacks cause pedestrian-type blunt injuries, run-over crush injuries, and people pinned under the vehicle. Gunshot wounds can occur if attackers also have weapons, but the main pattern is blunt trauma.

14. After a vehicle-ramming attack, the driver flees on foot into the crowd. Before entering, EMS should consider that:

    1. A. The truck is sure to catch fire soon
    2. B. The scene is safe once the truck stops
    3. C. Police will not respond to the scene
    4. D. The attacker may have other weapons
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    Answer: D. The attacker may have other weapons

    Ramming attackers have often carried knives, guns, or explosives and continued the attack on foot, so the scene is not safe until police control the threat. The stopped vehicle may also hold a device.

15. Tactical emergency casualty care (TECC) adapts military guidelines for civilian terror events by accounting for:

    1. A. Longer transport times to hospitals
    2. B. The use of armored vehicles for transport
    3. C. Children, older adults, and no body armor
    4. D. Care given by physicians on scene
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    Answer: C. Children, older adults, and no body armor

    TECC applies battlefield lessons to civilians of all ages who have no protective gear and includes bystanders and untrained rescuers. Transport times in cities are usually shorter, not longer, than in combat settings.

16. During an active terror attack, you are pinned behind a concrete pillar with a wounded police officer who is alert and has heavy bleeding from his thigh. Gunfire continues nearby. The best approach is to:

    1. A. Leave cover to drag him to the ambulance
    2. B. Have him apply his own tourniquet
    3. C. Pack the wound and hold pressure 3 min
    4. D. Fully assess his airway and breathing
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    Answer: B. Have him apply his own tourniquet

    In direct threat care, a casualty who can still use his hands should be directed to apply his own tourniquet while everyone stays behind cover. Leaving cover to move him exposes both of you to fire.

17. At a bombing, you reach three patients with heavy limb bleeding but carry only two tourniquets. The best action is to:

    1. A. Hold pressure on one and wait for more crews
    2. B. Split one tourniquet between two patients
    3. C. Load the first patient and leave the others
    4. D. Tourniquet the two worst, direct help on the third
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    Answer: D. Tourniquet the two worst, direct help on the third

    Tourniquets go to the patients bleeding most severely, while bystanders or lower-acuity patients are directed to hold firm direct pressure until more supplies arrive. Staying with one patient while two others bleed costs preventable lives.

18. At a mass shooting, bystander bleeding control matters most because:

    1. A. EMS entry may be delayed by the threat
    2. B. Most deaths occur hours later in surgery
    3. C. Tourniquets fail after the first minute
    4. D. Police officers carry no bleeding kits
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    Answer: A. EMS entry may be delayed by the threat

    Medical teams may not reach victims until the threat is controlled, and severe bleeding can kill in minutes, so the immediate responders are often bystanders. The idea that tourniquets work only in the first minute is false; early is better, but they help whenever bleeding is ongoing. Most preventable bleeding deaths happen within minutes, not hours later in surgery, and many police officers now carry tourniquets, but they may be busy stopping the threat.

19. DHS advice to civilians caught in an active attack is to:

    1. A. Run if possible, hide if not, and fight as a last resort
    2. B. Hide first, then run once police arrive on scene
    3. C. Fight first, then run, so the attacker is stopped quickly
    4. D. Lie down and play dead until the shooting stops
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    Answer: A. Run if possible, hide if not, and fight as a last resort

    'Run, hide, fight' teaches people to escape if there is a safe route, hide out of sight if not, and fight only when their lives are in immediate danger. Hiding first is tempting but wastes the chance to escape before the attacker arrives.

20. A truck bomb partly collapses a multistory office building. Among the people killed, most deaths will result from:

    1. A. Primary blast lung from the pressure wave
    2. B. Burns from the fireball and later fires
    3. C. Being crushed where the floors collapsed
    4. D. Deep cuts from flying window glass
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    Answer: C. Being crushed where the floors collapsed

    In the 1995 Oklahoma City bombing, about 87% of people in the collapsed part of the building died, compared with about 5% elsewhere, and structural collapse was the strongest risk factor for death, so response to a building bombing must plan for crush injuries and trapped victims. Primary blast lung kills mainly people very close to the explosion, especially in enclosed spaces. Fireball burns caused few deaths. Flying glass caused many injuries among survivors, even blocks away, but few deaths.

21. Reviews of terrorist bombings judge the EMS and hospital response largely by the:

    1. A. Total number of patients transported out
    2. B. Average scene time for each ambulance crew
    3. C. Number of agencies that responded
    4. D. Critical mortality among the severely hurt
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    Answer: D. Critical mortality among the severely hurt

    Critical mortality, the share of critically injured patients who die, measures how well the system sorted and delivered care. Counting transports or agencies says nothing about whether the sickest patients survived.

22. A wounded suspected suicide bomber lies on the ground wearing a vest with wires and pouches. You should:

    1. A. Remove the vest quickly so you can treat him
    2. B. Stay away and let bomb technicians clear him
    3. C. Cut the wires to disarm it before treatment
    4. D. Roll him over to check his back for wounds
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    Answer: B. Stay away and let bomb technicians clear him

    An injured bomber may still have a live device, a dead-man switch, or a backup trigger, so no one approaches until bomb technicians clear him. Cutting wires is tempting but can set off the device.

23. Pipe bombs filled with black powder cause injury mainly from:

    1. A. A supersonic overpressure wave
    2. B. Radiation released from the filler
    3. C. Toxic gas from the burning powder
    4. D. Fragments of the metal pipe
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    Answer: D. Fragments of the metal pipe

    Black powder is a low-order explosive that bursts the pipe into high-speed fragments rather than creating a true shock wave. A supersonic overpressure wave is the feature of high-order explosives such as TNT or C-4.

24. Plastic explosives such as C-4 and Semtex are best described as:

    1. A. Unstable homemade peroxide explosives
    2. B. Low-order propellants used in pipe bombs
    3. C. Stable, military-grade high explosives
    4. D. Incendiary gels that cling to skin
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    Answer: C. Stable, military-grade high explosives

    Plastic explosives are moldable, stable high explosives that need a detonator to go off, which makes them prized but harder for attackers to obtain. Unstable homemade peroxide explosives such as TATP are the opposite in stability.

25. A bombing victim has dozens of small puncture wounds from ball bearings but is alert with normal vital signs. You should assume that:

    1. A. Small wounds mean the injuries are minor
    2. B. Deep injuries may lie under small wounds
    3. C. The fragments have stayed in the skin
    4. D. He can safely leave without evaluation
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    Answer: B. Deep injuries may lie under small wounds

    High-speed fragments can travel deep into the chest, abdomen, or vessels through tiny entry wounds, and blast injuries may show up late. Judging severity by the size of the entry wound is the classic error.