Only trained healthcare providers should perform external pacing.

If possible, the skin should be prepared before the placement of the pacer pads. Hair should be removed, but not shaved as this can create a nidus for infection. The skin should be cleansed with an alcohol wipe to remove any dirt, debris, or sweat whenever possible to ensure maximum conduction between the pads and the skin.

Pacing pads are positioned on the patient's chest either in the anterolateral position of anteroposterior one. Multiple variations of pacer pad placement are equally effective. "Negative electrode in the left parasternal region, the positive electrode in the right subscapular region; a negative electrode in the left parasternal region, a positive electrode in the left subscapular region; or negative electrode at the cardiac apex or the position of lead V3, a positive electrode in the right parasternal region." As long as the apical/anterior pad is negative, precise electrode placement is not essential. The rate should be set between 60 to 90 beats per minute with the electrical output, also known as the current, set to its lowest setting. The rate should be slowly increased until a pacer spike is seen on the monitor. Continue to increase the rate until a QRS complex follows each spike. This indicates electrical capture. Confirmation of mechanical capture should be done by feeling for a pulse. Additionally, mechanical capture can be confirmed using ultrasound and by observing ventricular contraction. If the patient is conscious, little sedation can be considered to reduce the feeling of discomfort associated with cardiac pacing[12].

In subjects with normal left ventricular function, pacing may reduce stroke volume significantly. This change was also seen in patients with heart failure. Both external and internal pacing caused a reduction in ejection fraction. There were no significant differences between the reduction that external pacing caused and the internal reduction pacing caused. To maintain approximate cardiac output, the rate of pacing can be increased. 

Side effects of transcutaneous pacing include cutaneous burns and muscle contractions. Superficial injury from the pacing pads resembles mild folliculitis. It is well known that muscle contractions can be extremely painful. To the point that sedation/anesthesia may be required. While the muscle contractions can be painful, no skeletal or myocardial muscle injury (as measured by CK, CK-MB, and troponin blood levels) developed after 30 minutes of pacing at 38 to 70mA with rates 10-20% above resting heart rate. Most cases of cutaneous burns are mild. However, many cases having third-degree burns have been reported in neonates, children and geriatric age group after cardiac pacing [13][14]. Risk of burns likely increases when pacer pads are used against manufacture instructions and are reapplied for multiple uses.

Two promising new ways of non-invasive pacing are currently being studied to mitigate the side effects of current transcutaneous pacing techniques. The first uses high-intensity frequency ultrasound to stimulate pacing. The second uses iron microparticles injected intravenously and a generated magnetic field to pace in a concept known as mechano-electrical feedback.[15][10]

External pacing is one of the quickest and easiest methods for treating multiple types of conduction abnormalities. Everything from bradycardia to ventricular tachycardia can be managed with external pacing until definitive treatment can be implemented. Furthermore, it can be used under a variety of circumstances, ranging from drug-induced electrical disturbances to conduction system inhibition secondary to myocardial infarct. It can be applied in the hospital setting or used by emergency medical service (EMS) providers when transporting critically ill patients to maintain an adequate cardiac output to ensure enough organ perfusion [6].

External pacing is a procedure that is sometimes required on the medical and surgical floors. While the physician may actually initiate the pacing, it is the nurse who is primarily responsible for monitoring the patient. Hence, nurses have to be familiar with external pacing and its indications. Before the pacing is initiated, the patient should be educated about potential complications such as burns or failure to capture. The patient should also be informed about the potential discomfort of tingling or small shock-like nerve impulses. The nurse has to be fully aware that transcutaneous pacing may not always work and must be prepared to have a transvenous pacer system kit and atropine at the bedside. Finally, the nurse should make sure that no person may use their mobile phones or other electronic devices near the patient as this may interfere with the pacing unit. An appropriate warning sign needs to be placed on the door.[16][17][18]]. Studies have shown that the hemodynamic effects are similar between external pacing and internal right ventricular pacing. However, currently available studies do not show that transcutaneous pacing improves patient outcomes. Data available is very limited. Most studies available have sample sizes of less than 150 patients and the time to application of the pacing was greater than 20 minutes. Larger studies with earlier application times are needed to confirm the effect of transcutaneous pacing on patient outcomes [19]. Healthcare outcomes can also be improved by good coordination and communication between the health professionals team, which consists of physicians, nurses, cardiac physiologists, and intensivists. A strong doctor-patient relationship must be there.