Video footage and photos showed several midsized buildings in worst-hit Hualien county leaning at sharp angles, their lowest floors crushed into mangled heaps of concrete, shattered glass, bent iron beams and other debris.
Firefighters could be seen climbing ladders hoisted against windows as they sought to reach residents inside apartments.
The shallow, magnitude 6.4 quake that struck late last night caused at least four buildings to cave in and tilt dangerously.
A maintenance worker who was rescued after being trapped in the basement of the Marshal Hotel, whose ground floor had caved in, said the force of the earthquake was unusual.
"At first it wasn't that big ... we get this sort of thing all the time and it's really nothing. But then it got really terrifying," the worker, Chen Ming-hui, told Taiwan's official Central News Agency after he was reunited with his son and grandson following the quake. "It was really scary."
Two employees of the hotel were killed in the disaster, CNA said. Taiwan's National Fire Agency said rescuers freed another employee from the rubble.
Other buildings shifted on their foundations and rescuers used ladders, ropes and cranes to get residents to safety.
Six people were killed in the quake, while 256 others were injured and 88 left unaccounted for, according to the fire agency. CNA reported that seven had been killed.
The force of the tremor buckled roads and disrupted electricity and water supplies to thousands of households, the fire agency said.
Taiwanese President Tsai Ing-wen moved to reassure the Taiwanese public that every effort would be made to look for survivors. In a post on her official Facebook page, Tsai said she arrived in Hualien on Wednesday to review rescue efforts.
Tsai said she "ordered search and rescue workers not to give up on any opportunity to save people, while keeping their own safety in mind."
"This is when the Taiwanese people show their calm, resilience and love," she wrote. "The government will work with everyone to guard their homeland."
China's official Xinhua News Agency reported that the director of China's Taiwan Affairs office, Zhang Zhijun, said China was "willing to send a rescue team to Taiwan" to help with relief efforts, adding that he was aware of a shortage of rescue workers in the disaster area.
China Central Television reported that more than 40 of the missing people were trapped in the Yunmen Cuiti building, a 12-story apartment building. Rescue efforts at the building were suspended because the structure was sliding, according to Taiwan's Central Emergency Operation Center.
Taiwanese media reported that the Beautiful Life Hotel also was tilting. CNA posted photos showing a road fractured in several parts.
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