The 6.2 magnitude quake razed homes and buckled roads in a cluster of mountain communities 140km east of Rome.
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Rescue efforts continued through the night, said Luigi D’Angelo, an official with Italy’s Civil Protection Department.
Amatrice’s mayor had initially said 70 guests were in the crumbled hotel ahead of this weekend’s festival, but rescue workers later halved that estimate after the owner said most guests managed to escape.
CNN correspondent Frederik Pleitgen saw machinery moving in through the narrow lanes and rescuers using sniffer dogs to help find more bodies.
“In hard times, Italy knows what to do”, he said. “They believe it’s about 72 hours those people would be able to survive”, he said. “We can see several casualties related to this event”.
The rescuers, which include foreign crews, are also working through aftershocks – even one as powerful as a magnitude 5.5.
The scene was captured on video by CNN affiliate Sky TG24.
The firefighter clutches a girl, said to be 8 years old, and walks her out of the huge pile of rubble as a volley of cheers erupts.
“Come on. Come on”.
Suddenly there was a foot, and leg, then the other leg.
This is the extraordinary moment when, with hope fading for the chances of any survivors so long trapped under the rubble, a little girl no more than 10 years old was pulled out alive.
Global media reported that at least 73 people were killed in the disaster while more than 20 others had been rushed to hospitals.
The settlement now looks like a ghost town, with just a few residents trickling back to where their homes once stood.
“Many cases have shown in the past that even after two days people can be rescued alive”, he said.
Aerial video taken by drones showed swathes of Amatrice, a year ago voted one of Italy’s most lovely historic towns, completely flattened.
Some 264 of the wounded have been hospitalized.
The death toll is expected to rise as rescue teams work through the rubble, with regular aftershocks posing a continuing threat.
Italian Prime Minister Matteo Renzi is helping coordinate rescue efforts with authorities, the Italian Council of Ministers said in a statement.
The quake, which struck some 140 kilometres east of Rome, was Italy’s most powerful since the 2009 disaster in L’Aquila.
Emma Tucker, deputy editor of British newspaper The Times, was in Italy’s Marche region, about 85 kilometers from the epicenter, when her house started “trembling, shaking … an absolutely appalling noise”.
Italy is no stranger to deadly quakes.
The death toll from a devastating quake in central Italy rose to at least 247 people early on Thursday after rescue teams worked through the night to try to find survivors under the rubble of flattened towns. The natural disaster Wednesday struck an area close to the 2009 quake.
Italy’s natural disaster institute, INGV, said the epicentre was near Accumoli and Amatrice, which lie between the larger towns of Ascoli Piceno to the northeast and Rieti to the southwest.
The country’s most deadly earthquakes since the start of the 20th century came in 1908, when an natural disaster followed by a tsunami killed an estimated 80,000 people in the southern regions of Reggio Calabria and Sicily. In Arquata del Tronto, which includes Pescara del Tronto, 46 were killed.
It cited that building types tend to be un-reinforced brick with mud and concrete frame with infill construction.
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Sergio Perozzi, the mayor of Amatrice, told RAI “roads in and out of town are cut off”.
