Abstract Cardiogenic shock (CS) is a desaese burdened by high mortality rates, but lower in high–volume cardiology centers. Early diagnosis and intensive treatment are essential for prognosis. In our low–volume center, for menagement of CS, is used a protocol based on arterial blood gas analysis serial monitoring, invasive blood pressure, echocardiographic hemodynamic parameters; underlying acute ischemia revascularisation; non–invasive mechanical ventilation; use of inotropic/vasopressors drugs and eventually circulatory support by aortic counterpulsation (IABP). Starting from hemodynamic characteristics of the patient, clinician is so supported in his choices in order to achieve an adequate peripheral perfusion. In case of failure to reach targets for each parameter, meaning the persistent shock status, the protocol helps to select patients with low probability of cardiac function recovery and those with age, comorbidities and life expectancy, deserving extracorporeal membrane oxygenation as a bridge to recovery, transplant or ventricular assist device at a high–volume center. The management of CS in our low–volume center could benefit of Impella, an advanced circulatory support allowing the left ventricular unloading and a more likely patient stabilization until the transfer to high–volume center. In low–volume centers, IABP often is the only option avaliable in CS not responsive to inotropic and vasopressors drugs. However, at present, little evidence in literature support its use. A promptly stratification of patient severity prevents to underestimate pre–shock signs and avoids delays causing further hemodynamic worsening. We think that is necessary to build a CS network, similar to that for percutaneous treatment of ST–elevation myocardial infarction.