The presentation of cardiogenic shock in the emergency department is highly variable-ranging from overt cases such as cardiac arrest in STEMI patients to far more subtle and insidious forms. While shock states like sepsis and hypovolemia often receive the most attention, cardiogenic shock carries a mortality rate of up to 80% in some studies. Recent evidence, including the DanGer Shock trial, underscores the importance of early recognition and intervention. However, when patients present in an undifferentiated shock state, accurate and timely diagnosis is the critical first step. In this session, we will present a three-step approach to echocardiographic diagnosis of heart failure for all emergency physicians, discuss the utility of SCAI shock staging in clinical practice, and review key indications for referral to centers capable of providing advanced mechanical circulatory support.